How Does Psychotherapy Work

How Does Psychotherapy Work? Martha Stark, M.D.

Copyright © 2016 Martha Stark, M.D. e-Book 2016 International Psychotherapy Institute All Rights Reserved This e-book contains material protected under International and Federal Copyright Laws and Treaties. This e-book is intended for personal use only. Any unauthorized reprint or use of this material is prohibited. No part of this book may be used in any commercial manner without express permission of the author. Scholarly use of quotations must have proper attribution to the published work. This work may not be deconstructed, reverse engineered or reproduced in any other format. Created in the United States of America

I dedicate this to my dear sweet Gunnar, my life partner without whom none of this would have been possible; to my dear publisher, Jason Aronson, who has always been a source of inspiration to me and has so generously given me the gift of encouraging me to go wherever my heart leads me; and to all the patients, supervisees, students, and colleagues whom I have known and loved over the course of my career.

Table of Contents INTRODUCTION Part 1

HOW DOES PSYCHOTHERAPY WORK? Conclusion References Part 2

Module 1: The Healing Process and Transformation of Defense into Adaptation Module 2: Chaos Theory and Psychic Inertia Module 3: The Goldilocks Principle and Controlled Damage Module 4: The Sandpile Model and the Paradoxical Impact of Stress Module 5: The Web of Life and Resilience Module 6: A Holistic Conceptual Framework and the Impact of Psychological and Physiological Stressors Module 7: The Ultimate Goal of Psychodynamic Psychotherapy and Belated

Mastery Module 8: Optimal Stress and Precipitating Disruption to Trigger Repair Module 9: Three Modes of Therapeutic Action and Three Optimal Stressors Module 10: Traumatic Frustration and 1-Person vs. 2-Person Defenses Module 11: Therapeutic Induction of Healing Cycles of Disruption and Repair Module 12: Ambivalent Attachment to Dysfunctional Defense and Neurotically Conflicted About Healthy Desire Module 13: Growth-Promoting but Anxiety-Provoking Conflict Statements Module 14: Recursive Cycles of Challenge and Support and Locating the Conflict Within the Patient Module 15: Cognitive Dissonance and from Structural Conflict to Structural Collaboration Module 16: Nature vs. Nurture and I-It vs. I-Thou Relationships Module 17: Corrective Provision vs. Authentic Engagement

Module 18: Positive Transference Disrupted vs. Negative Transference Module 19: Symbolic Corrective for Early-On Deprivation and Neglect Module 20: Grieving, Relenting, and Forgiveness Module 21: Relentless Hope and the Illusion of Omnipotent Control Module 22: Relational vs. Internal Sadomasochistic Psychodynamics Module 23: Disillusionment Statements and Adaptive Transmuting Internalization Module 24: Objective Neutrality vs. Empathic Attunement vs. Authentic Engagement Module 25: Enactment and the Patient as Intentioned Module 26: Relational Interventions and Accountability Statements Module 27: Containment and the Capacity to Relent Module 28: Introjective Identification and a Certain Beauty in Brokenness

References

INTRODUCTION I have always found the following quote from Gary Schwartz’s 1999 The Living Energy Universe to be inspirational: “One of science’s greatest challenges is to discover certain principles that will explain, integrate, and predict large numbers of seemingly unrelated phenomena.” So too my goal has long been to be able to tease out overarching principles – themes, patterns, and repetitions – that that are relevant in the deep healing work that we do as psychotherapists. Drawing upon concepts from fields as diverse as systems theory, chaos theory, quantum mechanics, solid-state physics, toxicology, and psychoanalysis to inform my understanding, on the pages that follow I will be offering what I hope will prove to be a clinically useful conceptual framework for understanding how it is that healing takes place – be it of the body or of the mind. More specifically, I will be speaking both to what exactly provides the therapeutic leverage for healing chronic dysfunction and to how we, as psychotherapists, can facilitate that process? Just as with the body, where a condition might not heal until it is made acute, so too with the mind. In other words, whether we are dealing with body or mind, superimposing an acute injury on top of a

chronic one is sometimes exactly what a person needs in order to trigger the healing process. More specifically, the therapeutic provision of “optimal stress” – against the backdrop of empathic attunement and authentic engagement – is often the magic ingredient needed to overcome the inherent resistance to change so frequently encountered in our patients with longstanding emotional injuries and scars. Too much challenge (traumatic stress) will overwhelm. Too little challenge (minimal stress) will serve simply to reinforce the dysfunctional status quo. But just the right combination of challenge and support (optimal stress) will “galvanize to action” and provoke healing. I refer to this as the Goldilocks Principle of Healing. And so it is that with our finger ever on the pulse of the patient’s level of anxiety and capacity to tolerate further challenge, we formulate “incentivizing statements” strategically designed “to precipitate disruption in order to trigger repair.” Ongoing use of these optimally stressful interventions will induce healing cycles of defensive destabilization followed by adaptive restabilization at ever-higher levels of integration, dynamic balance, and functional capacity. Behind this “no pain, no gain” approach is my firm belief in the

underlying resilience that patients will inevitably discover within themselves once forced to tap into their inborn ability to self-correct in the face of environmental challenge – an innate capacity that will enable them to advance, over time, from dysfunctional defensive reaction to more functional adaptive response. Indeed the health of a system is a story about its capacity to adapt, that is, its ability to restore its homeostatic balance in the face of challenge. Ultimately, the goal of any holistic treatment – be its focus psychological and/or physical – must therefore be to restore the intrinsic orderedness and fluidity of the MindBodyMatrix and the system can thereby more effectively adapt to the “stress of life.” In the psychological realm, an example of adaptation would be handling the stress of the loss of a loved one by confronting – and grieving – the pain of one’s heartbreak and ultimately evolving from anger, upset, and feelings of helplessness to serene acceptance. In the physiological realm, an example of adaptation would be handling the stress of blocked coronary arteries by developing new (collateral) ones to supply the heart with the nutrients and oxygen it needs, thereby averting a potential heart attack. The premise of How Does Psychotherapy Work? is that

psychodynamic psychotherapy affords the patient an opportunity – albeit a belated one – to master experiences that had once been overwhelming, and therefore defended against, but that can now, with enough support from the therapist and by tapping into the patient's underlying resilience and capacity to cope with stress, be processed, integrated, and ultimately adapted to. This opportunity for belated mastery of traumatic experiences and transformation of defense into adaptation speaks to the power of the transference, whereby the hereand-now is imbued with the primal significance of the there-and-then. Ultimately, the therapeutic goal is to transform less-evolved defense into more-evolved adaptation – for example, from externalizing blame to taking ownership, from whining and complaining to becoming proactive, from dissociating to becoming more present, from feeling victimized to becoming empowered, from being jammed up to harnessing one's energies so that they can be channeled into the pursuit of one's dreams, from denial to confronting head-on, from being critical to becoming more compassionate, and from cursing the darkness to lighting a candle. Growing up (the task of the child) and getting better (the task of the patient) are therefore a story about transforming need into capacity – as further examples, the need for immediate gratification into the capacity

to tolerate delay, the need for perfection into the capacity to tolerate imperfection, the need for external regulation of the self into the capacity to be internally self-regulating, and the need to hold on into the capacity to let go. In sum, it could be said that, as the result of a successful psychodynamic treatment, "resistance" will be replaced by "awareness" and "actualization of potential" (Model 1), "relentless pursuit of the unattainable" will be replaced by "acceptance" (Model 2), and "reenactment of unresolved childhood dramas" will be replaced by "accountability" (Model 3). This book represents my effort to provide a comprehensive summary of how I conceptualize the Three Modes of Therapeutic Action (enhancement of knowledge, provision of corrective experience, and engagement in authentic relationship), about which I have been writing for the past 25 years. In an effort to make some fairly complex material as accessible as possible, I have made the exciting decision to present my conceptual overview of how psychotherapy works in two different formats. First, I offer my ideas as a narrative – tracing the evolution of psychodynamic psychotherapy from classical psychoanalysis (with its emphasis on the

ego) to self psychology and other deficit theories (with their emphasis on the self) to contemporary relational theories (with their emphasis on the self-in-relation); but the majority of the book is devoted to PowerPoint Slides, each one of which is intended to tell a story… In this second part of the book, there are 28 Modules, each one of which has a specific focus and contains anywhere from 8 to 19 PowerPoint Slides. Many of the slides are overview slides that organize the material in what I hope will be an easy to digest and satisfyingly balanced fashion – for both those familiar with my work and those for whom this will be their first exposure. So please settle in, buckle up, kick back, and enjoy! You’ll be in for quite a ride!! Although the slides do not encompass every thought I have ever had about the process of healing, they come pretty close!! Martha Stark, MD Cambridge, Massachusetts

Part 1

HOW DOES PSYCHOTHERAPY WORK? What is it that enables patients to get better? How does psychotherapy work? How do we conceptualize the process by which patients grow and change? I have developed an integrative model of therapeutic action that takes into consideration many different schools of thought. It is my belief, however, that most psychotherapeutic models boil down to advocating either knowledge, experience, or relationship – that is, either enhancement of knowledge, provision of experience, or engagement in relationship – as the primary therapeutic agent (Stark 1994a, 1994b, 1999). I will therefore begin by summarizing these three different models of therapeutic action. As will soon become clear, although there is significant overlap amongst the three perspectives, each one contains elements that distinguish it from the other two. The models of therapeutic action are therefore not mutually exclusive but mutually enhancing. And if our goal is to optimize the therapeutic potential of each moment, we will be most effective if we have a deep appreciation for, and some facility with, all three modalities.

The Interpretive Perspective of Classical Psychoanalysis The first is the interpretive model of classical psychoanalysis. Structural conflict is seen as the villain in the piece and the goal of treatment is thought to be a strengthening of the ego by way of insight. Whether expressed as (a) the rendering conscious of what had once been unconscious (in topographic terms); (b) where id was, there shall ego be (in structural terms); or (c) uncovering and reconstructing the past (in genetic terms), in Model 1 it is the truth that is thought to set the patient free. Interpretations, particularly of the transference, are considered the means by which self-awareness is expanded.

Resolution of Structural Conflict How do interpretations lead to resolution of structural conflict? As the ego gains insight by way of interpretation, the ego becomes stronger. This increased ego strength enables it to experience less anxiety in relation to the id's sexual and aggressive impulses; the ego's defenses, therefore, become less necessary. As the defenses are gradually relinquished, the patient's conflicts about her sexual and aggressive drives are gradually resolved.

The Therapist as an Objective Observer The Model 1 therapist sees herself not as a participant in a relationship but as an objective observer of the patient. Her unit of study is the patient and the patient's internal dynamics. The therapist conceives of her position as outside the therapeutic field and of herself as a blank screen onto which the patient casts shadows that the therapist then interprets. Model 1 is clearly a one-person psychology.

Freud’s Bias In some ways it is not surprising that Freud would have been reluctant to recognize the importance of the actual relationship – because Freud never had any relationship whatsoever with an analyst. His, of course, was a self-analysis. By way of a meticulous analysis of his dreams, he was able to achieve insight into the internal workings of his mind, thereby strengthening his ego and resolving his intrapsychic conflicts.

The Transition to a More Relational Perspective But there were those analysts both here and abroad who found

themselves dissatisfied with a model of the mind that spoke to the importance not of the relationship between patient and therapist but of the relationships amongst id, ego, and superego. Both self psychologists in the United States and object relations theorists in Europe began to speak up on behalf of the individual as someone who longed for connection with others. In fact, Fairbairn (1963), writing as early as the 1940s, contended that the individual had an innate longing for object relations and that it was the relationship with the object and not the gratification of impulses that was the ultimate aim of libidinal striving. He noted that the libido was "primarily object-seeking, not pleasure-seeking."

Nature vs. Nurture Both the self psychologists and the European (particularly the British) object relations theorists were interested not so much in nature (the nature of the child's drives) but in nurture (the quality of maternal care and the mutuality of fit between mother and child). Whereas Freud and other classical psychoanalysts conceived of the patient's psychopathology as deriving from the patient (in whom there was thought to be an imbalance of forces and, therefore, internal conflict), self psychologists, object relations theorists, and contemporary

relational analysts conceive of the patient's psychopathology as deriving from the parent (and the parent's failure of the child).

Internal Recording of Parental Failures How were such parental failures thought to be internally recorded and structuralized? Interestingly, some theorists (Balint 1968) focused on the price the child paid because of what the parent did not do; in other words, absence of good in the parent/child relationship was thought to give rise to structural deficit (or impaired capacity) in the child. But other theorists (Fairbairn 1963) focused on the price the child paid because of what the parent did do; in other words, presence of bad in the parent/child relationship was thought to be internally registered in the form of pathogenic introjects or internal bad objects – filters through which the child would then experience her world. But whether the pathogenic factor was seen as an error of omission (absence of good) or an error of commission (presence of bad), the villain in the piece was no longer thought to be the child but the parent – and, accordingly, psychopathology was no longer thought to derive from the child's nature but from the nurture the child had received during her formative years. No longer was the child considered an agent (with unbridled sexual and aggressive drives); now the parent was held

accountable – and the child was seen as a passive victim of parental neglect and abuse.

From Insight to Corrective Experience When the etiology shifted from nature to nurture, so too the locus of the therapeutic action shifted from insight by way of interpretation to corrective experience by way of the real relationship (that is, from within the patient to within the relationship between patient and therapist). No longer was the goal thought to be insight and rendering conscious the unconscious so that structural conflict could be resolved; now the goal of treatment became filling in structural deficit and consolidating the self by way of the therapist's restitutive provision. With the transitioning from a one-person to a two-person psychology, sexuality (the libidinal drive) and aggression took a back seat to more relational needs – the need for empathic recognition, the need for validation, the need to be admired, the need for soothing, the need to be held.

From Drive Object to Good Object The therapist was no longer thought to be primarily a drive object

but, rather, either a selfobject (used to complete the self by performing those functions the patient was unable to perform on her own) or a good object/good mother (operating in loco parentis). To repeat: The deficiency-compensation model – embraced by the self psychologists and by those object relations theorists who focused on the internal recording of traumatic parental failure in the form of deficit – conceived of the therapeutic action as involving some kind of corrective experience at the hands of a therapist who was experienced by the patient as a new good (and, therefore, compensatory) object.

From Structural Conflict to Structural Deficit In Model 2, then, the patient was seen as suffering not from structural conflict but from structural deficit – that is, an impaired capacity to be a good parent unto herself. The deficit was thought to arise in the context of failure in the early-on environmental provision, failure in the early-on relationship between parent and infant. Now the therapeutic aim was the therapist's provision in the hereand-now of that which was not provided by the parent early-on – such that the patient would have the healing experience of being met and held.

Experience vs. Actual Participation Of note is that some deficiency-compensation theorists (most notably the self psychologists) focused on the patient's experience of the therapist as a new good object; others (the Model 2 object relations theorists) appeared to focus more on the therapist's actual participation as that new good object. But what all the deficiency-compensation models of therapeutic action had in common was that they posited some form of corrective provision as the primary therapeutic agent.

A “New Beginning” It was then in the context of the new relationship between patient and therapist that there was thought to be the opportunity for a new beginning (Balint 1968) – the opportunity for reparation, the new relationship a corrective for the old one.

“I-It” vs. “I-Thou” But although relationship was involved, it was more an I-It than an I-Thou relationship (Buber 1966) – more a one-way relationship between someone who gave and someone who took than a two-way

relationship involving give-and-take, mutuality, and reciprocity. It is for this reason that self psychology, which is a prime example of a deficiency-compensation model, has been described as a one-and-ahalf-person psychology (Morrison 1997) – it is certainly not a one-person psychology, but then nor is it truly a two-person psychology. And Michael Balint (1968) – also an advocate of the correctiveprovision approach – speaks directly to the I-It aspect of the patient/therapist relationship with the following: "It is definitely a twoperson relationship in which, however, only one of the partners matters; his wishes and needs are the only ones that count and must be attended to; the other partner, though felt to be immensely powerful, matters only in so far as he is willing to gratify the first partner's needs and desires or decides to frustrate them; beyond this his personal interests, needs, desires, wishes, etc., simply do not exist" (p. 23). In other words, the emphasis in a deficiency-compensation model is not so much on the relationship per se as it is on the filling in of the patient's deficits by way of the therapist's corrective provision. But this relationship between a person who provides and a person who is the recipient of such provision is a far cry from the relationship that exists between two real people – an intersubjective relationship that

involves two subjects, both of whom contribute to what transpires at the intimate edge (Ehrenberg 1992) between them. And so it is that (in the past twenty or twenty-five years) some contemporary theorists have begun to make a distinction between the therapist's provision of a corrective experience for the patient and the therapist's participation in a real relationship with the patient – a distinction between the therapist's participation as a good object (Model 2) and the therapist's participation as an authentic subject (Model 3).

Give vs. Give-and-Take We are speaking here to the distinction between a model of therapeutic action that conceives of the therapy relationship as involving give (the therapist's give) and a model that conceives of the therapy relationship as involving give-and-take (both participants giving and taking).

Empathic Attunement vs. Authentic Engagement In Model 2, the emphasis is on the therapist's empathic attunement to the patient – which requires of the therapist that she decenter from her own experience so that she can immerse herself empathically in the patient's experience. We might say of the Model 2 therapist that she

enters into the patient's experience and takes it on as if it were her own. By contrast, in Model 3, the emphasis is on the therapist's authentic engagement with the patient – which requires of the therapist that she remain very much centered within her own experience, ever attuned to all that she is feeling and thinking. We might say of the Model 3 therapist that she allows the patient's experience to enter into her and takes it on as her own. Although empathic attunement and authentic engagement may sometimes go hand in hand, they involve a different positioning of the therapist and, therefore, a different use of the therapist's self. Let me now offer a clinical vignette that I think demonstrates the distinction between empathic decentering and authentic centering.

Clinical Vignette: Empathy vs. Authenticity Many years ago I was seeing a chronically depressed and suicidal patient who had just been diagnosed with breast cancer. Shortly thereafter she came into a session having learned that her axillary lymph nodes had tested negative (that is, no cancer). Through angry tears, she told me that she was upset about the results because she had hoped the cancer would be her ticket out.

I had to think for a few moments but then I managed to say softly: "At times like this, when you're hurting so terribly inside and feeling such despair, you find yourself wishing that there could be some way out, some way to end the pain." In response to this, she began to cry much more deeply and said, with heartfelt anguish, that she was just so tired of being so lonely all the time and so frightened that her (psychic) pain would never, ever go away. Eventually she went on to say that she realized now how desperate she must have been to be wishing for an early death from cancer. What I managed to say was, I think, empathic; but to say it, I needed to put aside my own feelings so that I could listen to my patient in order to understand where she was coming from. And so my response, although empathic, was not at all authentic – because what I was really feeling was horror. What I was really feeling about my patient's upset with her negative test results was "My God, how can you think such an outrageous thing!" To have said that would have been authentic – but probably not analytically useful! Although the response I offered my patient was not authentic, it was empathic. And I think it enabled her to feel understood and then to

access deeper levels of her pain and her anguish – and, eventually, her own horror that she would have been so desperate as to want cancer. Now, had I been able to process my countertransferential reaction of horror more quickly, I might have been able to say something that would have been both authentic and analytically useful, something to the effect of: "A part of me is horrified that you would want so desperately to find a way out that you would even be willing to have (metastasizing) cancer, but then I think about your intense loneliness and the pain that never lets up – and I think I begin to understand better." I present this example because it highlights the distinction between an empathic response and a more authentic response, between empathic attunement (Model 2) and authentic engagement (Model 3).

From Corrective Experience to Interactive Engagement Let us return to the issue of what constitutes the therapeutic action. There are an increasing number of contemporary theorists who believe that what heals the patient is neither insight nor a corrective experience. Rather, what heals, they suggest, is interactive engagement with an authentic other; what heals is the therapeutic relationship itself – a

relationship that involves not subject and drive object, not subject and selfobject, not subject and good object, but, rather, subject and subject, both of whom bring themselves (warts and all) to the therapeutic interaction, both of whom engage, and are engaged by, the other.

Mutuality of Impact Relational (or Model 3) theorists who embrace this perspective conceive of patient and therapist as constituting a co-evolving, reciprocally mutual, interactive dyad – each participant both proactive and reactive, each both initiating and responding. For the relational therapist, the locus of the therapeutic action always involves this mutuality of impact – a prime instance of which is projective identification.

Clinical Vignette: In a Heartbeat A patient's beloved grandmother has just died. The patient, unable to feel his sadness because it hurts too much, recounts in a monotone the details of his grandmother's death. As the therapist listens, she feels herself becoming intensely sad. As the patient continues, the therapist finds herself uttering, almost inaudibly, an occasional "Oh, no!" or "That's awful!" As the hour progresses, the patient himself becomes increasingly

sad. In this example, the patient is initially unable to feel the depths of his grief about his grandmother's death. By reporting the details of her death in the way that he does, the patient is able to get the therapist to feel what he cannot himself feel; in essence, the patient exerts interpersonal pressure on the therapist to take on as the therapist's own what the patient does not yet have the capacity to experience. This is clearly an instance of the patient's impact on the therapist. As the therapist sits with the patient and listens to his story, she finds herself becoming very sad, which signals the therapist's quiet acceptance of the patient's disavowed grief. We could say of the patient's sadness that it has found its way into the therapist, who has taken it on as her own. The therapist's sadness is therefore co-created – it is in part a story about the patient (and his disavowed grief) and in part a story about the therapist (in whom a resonant chord has been struck). The therapist, with her greater capacity (in this instance, to experience affect without needing to defend against it), is able both to tolerate the sadness that the patient finds intolerable and to process it psychologically. It is the therapist's ability to tolerate the intolerable that makes the patient's previously unmanageable feelings more manageable

for him. The patient's grief becomes less terrifying by virtue of the fact that the therapist has been able to carry that grief on the patient's behalf. A more assimilable version of the patient's sadness is then returned to the patient in the form of the therapist's heartfelt utterances – and the patient finds himself now able to feel the pain of his grief, now able to carry that pain on his own behalf. This is clearly an instance of the therapist's impact on the patient. For the relational therapist, the locus of the therapeutic action always involves mutual influence; both patient and therapist are continuously changing by virtue of being in relationship with each other.

The Patient as Proactive Unlike Model 2, which pays relatively little attention to the patient's proactivity in relation to the therapist, Model 3 addresses itself specifically to the force-field created by the patient in an effort to draw the therapist in to participating in ways specifically determined by the patient's early-on history and internally recorded in the form of pathogenic introjects – ways the patient needs the therapist to participate if she (the patient) is ever to have a chance to master her internal demons.

Re-finding the Old Bad Object More specifically, in a relational model of therapeutic action, the patient with a history of early-on traumas is seen, then, as having a need to re-find the old bad object – the hope being that perhaps this time there will be a different outcome. In order to demonstrate the distinction between a theory that posits unidirectional influence (a corrective-provision model) and a theory that posits bidirectional – reciprocal – influence (a relational model), I offer the following:

Inevitability of Empathic Failure As we know, self psychology (the epitome of a corrective-provision model) speaks to the importance of the therapist's so-called inevitable empathic failures (Kohut 1966). Self psychologists contend that these failures are unavoidable because the therapist is not, and cannot be expected to be, perfect. How does relational theory conceive of such failures? Many relational theorists believe that a therapist's failures of her patient are not just a story about the therapist (and her lack of perfection) but also a story about the patient and the patient's exerting of interpersonal

pressure on the therapist to participate in ways both familial and, therefore, familiar (Mitchell 1988). Relational theory believes that the therapist's failures do not simply happen in a vacuum; rather, they occur in the context of an ongoing, continuously evolving relationship between two real people – and speak to the therapist's responsiveness to the patient's (often unconscious) enactment of her need to be failed.

Repetition Compulsion As with every repetition compulsion, the patient's need to recreate the early-on traumatic failure situation in the therapy relationship has both unhealthy and healthy aspects. (1) The unhealthy component has to do with the patient's need to have more of same, no matter how pathological, because that's all the patient has ever known. Having something different would create anxiety because it would highlight the fact that things could be, and could therefore have been, different; in essence, having something different would challenge the patient's attachment to the infantile (parental) object. (2) But the healthy piece of the patient's need to be now failed as

she was once failed has to do with her need to have the opportunity to achieve belated mastery of the parental failures – the hope being that perhaps this time there will be a different outcome, a different resolution. And so it is that in a relational model, the therapist's failures of her patient are thought to be co-constructed – both a story about the therapist (and what she gives/brings to the therapeutic interaction) and a story about the patient (and what she gives/brings to the therapeutic interaction).

Clinical Vignette: My Refusal to Believe I would like to offer a vignette that speaks to the power of the patient's (unconscious) need to be failed – and its impact on the therapist. My patient, Celeste, had been telling me for years that her mother did not love her. Again and again she would complain bitterly about all the attention her mother showered on Celeste’s sisters. Celeste claimed that she, on the other hand, was treated by mother with either indifference or actual disdain. Of course I believed her; that is, of course I believed that this was her experience of what had happened as she was growing up. I wanted

to be very careful not to condemn Celeste's mother as unloving. My fear was that were I to agree with her that her mother did not love her, I would be reinforcing a distorted perception, which might then make it much more difficult for Celeste to reconcile with her mother at some later point, were she ever to decide to do that. And so I was always very careful never to say things like: "Your mother clearly did not love you," "Your mother obviously favored your sisters over you," or "Your mother had very little to give you." Instead, I would frame my empathic interventions in the following way: "And so your experience was that your mother did not love you – and that broke your heart." Or I would say something like, "How painful it must have been to have had the experience of wanting your mother's love so desperately and then feeling that you got so little of it." In retrospect, it makes me sad to think that I said these things and that Celeste let me. Part of her problem was that she allowed people to say these kinds of things to her. But one day she came to the session bearing a letter from her mother. She began to read it to me, and I was horrified. It was totally clear, beyond a shadow of a doubt, that for whatever the reason, her mother really did not love her in the way that she loved her other

daughters. It was a horrible letter and my heart ached for Celeste; now I really understood what she had meant all those years. And I felt awful that I had thought my patient's perceptions of her mother might be distortions of reality. When Celeste had finished reading one of the saddest letters I have ever heard, I said, "Oh, my God, your mother really doesn't love you as much as she loves the others, does she? I'm so sorry that it took me so long to get that." Celeste then hung her head and said quietly, with a mixture of anguish and relief, "You're right. My mother really doesn't love me very much." She began to sob in a way that I had never before heard her sob. I am sure that she was crying both about how unloved she had always been by her mother and about how disappointed she was now in me, that it had taken me so long to understand something so important. On some level, unconsciously I had been defending her mother. I think I was having trouble believing that her mother would have been so heartless as to favor her other daughters over my patient; I was so fond of my patient that I could not imagine any mother not loving her. The reality is that I had not really taken Celeste seriously when she had told me that her mother did not love her. I understood that she had

felt unloved as a child, but I could not bear to think that she had actually been unloved. And so I did her a grave disservice in assuming that she was inaccurately perceiving the reality of the situation. In doing this, I was blocking some of the grieving that she needed to do about her mother. By the way, as Celeste grieved the reality of how unloved she had actually been by her mother, she and I came to discover something else: Although she had not been loved by her mother, she had in fact been deeply loved and cherished by her father, a man who, although severely alcoholic and often absent from home, was nonetheless very deeply attached to Celeste and proud of her. We might never have gained access to the special connection with her father had I persisted in my belief that Celeste's mother had to have loved her. Let me add, at this point, that another way to understand what happened between Celeste and me is to think in terms of my patient as having needed me to fail her as she had been failed in the past, so that she would have the opportunity to achieve belated mastery of her old pain about not being taken seriously. Such a perspective (a relational or interactive perspective) would see the therapist's failure of her patient as not just a story about the

therapist (and the therapist's limitations) but also a story about the patient (and the patient's need to be failed). More generally, relational theorists believe that there are times when the patient needs not only to find a new good object but also to refind the old bad one, needs not only to create a new good object but also to re-create the old bad one – so that there can be an opportunity for the patient to revisit the early-on traumatic failure situation and perhaps, this time, to achieve mastery of it.

The Patient’s Transferential Activity as an Enactment In Model 3, then, the patient is seen as an agent, as proactive, as able to have an impact, as exerting unrelenting pressure on the therapist to participate in ways that will make possible the patient's further growth. The relational therapist, therefore, attends closely to what the patient delivers of herself into the therapy relationship (in other words, the patient's transferential activity). In fact, relational theory conceptualizes the patient's activity in relation to the therapist as an enactment, the unconscious intent of which is to engage (or to disengage) the therapist in some fashion – either by way of eliciting some kind of response from the therapist or by way of communicating something important to the therapist about the patient's

internal world. In fact, the patient may know of no other way to get some piece of her subjective experience understood than by enacting it in the relationship with her therapist.

Provocative vs. Inviting vs. Entitled I use the word provocative to describe the patient's behavior when she is seeking to recreate the old bad object situation (so that she can rework her internal demons), inviting to describe her behavior when she is seeking to create a new good object situation (so that she can begin anew), and entitled to describe her behavior when, confronted with an interpersonal reality that she finds intolerable, she persists even so – relentless in her pursuit of that to which she feels entitled and relentless in her outrage at its being denied.

The Therapist as Container for the Patient’s Projections If the Model 3 therapist is to be an effective container for – and psychological metabolizer of – the patient's disavowed psychic contents, the therapist must be able not only to tolerate being made into the patient's old bad object but also to extricate herself (by recovering her objectivity and, thereby, her therapeutic effectiveness) once she has allowed herself to be drawn in to what has become a mutual enactment.

The therapist must have both the wisdom to recognize and the integrity to acknowledge her own participation in the patient's enactments; even if the problem lies in the intersubjective space between patient and therapist, with contributions from both, it is crucial that the therapist have the capacity to relent – and to do it first. Patient and therapist can then go on to look at the patient's investment in getting her objects to fail her, her compulsive need to recreate with her contemporary objects the early-on traumatic failure situation.

Failure of Engagement vs. Failure of Containment If the therapist never allows herself to be drawn in to participating with the patient in her enactments, we speak of a failure of engagement. If, however, the therapist allows herself to be drawn in to the patient's internal dramas but then gets lost, we speak of a failure of containment – and the potential is there for the patient to be retraumatized. Although initially the therapist may indeed fail the patient in much the same way that her parent had failed her, ultimately the therapist challenges the patient's projections by lending aspects of her otherness, or, as Winnicott (1965) would have said, her externality to the interaction – such that the patient will have the experience of something that is

other-than-me and can take that in. What the patient internalizes will be an amalgam, part contributed by the therapist and part contributed by the patient (the original projection). In other words, because the therapist is not, in fact, as bad as the parent had been, there can be a better outcome. There will be repetition of the original trauma but with a much healthier resolution this time – the repetition leading to modification of the patient's internal world and integration on a higher level.

A Corrective Relational Experience It is in this way that the patient will have a powerfully healing corrective relational experience, the experience of bad-become-good. In the relational model, it is the negotiation of the relationship and its vicissitudes (a relationship that is continuously evolving as patient and therapist act/react/interact) that constitutes the locus of the therapeutic action. It is what transpires in the here-and-now engagement between patient and therapist that is thought to be transformative. And so this third model of therapeutic action is the relational (or interactive) perspective of contemporary psychoanalytic theory. No

longer is the emphasis on the therapist as object – object of the patient's sexual and aggressive drives (Model 1), object of the patient's narcissistic demands (Model 2), or object of the patient's relational need to be met and held (Model 2). In this contemporary relational model, the focus is on the therapist as subject – an authentic subject who uses the self (that is, uses her countertransference) to engage, and to be engaged by, the patient. Unless the therapist is willing to bring her authentic self into the room, the patient may end up analyzed – but never found.

Clinical Vignette: A Provocative Enactment Let me now present another example that I believe highlights the difference between empathic attunement (the province of Model 2) and authentic engagement (the province of Model 3). I owe a debt of gratitude to one of my supervisees (Carole), who gave me permission to share the following vignette. John, a very handsome 59-year-old man, had been in therapy with Carole (a very attractive 66-year-old woman) for many years. Although Carole knew that her (characterological) tendency to be hoveringly overprotective – and sometimes, even, a bit intrusive – might have been

making John feel somewhat uncomfortable, nonetheless the therapy was progressing well. Furthermore, John was clearly attached to Carole, as she was to him. But, in 2008, when Barack Obama was elected to the White House, John made a denigrating racial remark that had a profound impact on how Carole then began to feel toward John – an impact that, although subtle, Carole simply could not shake. After Obama won the presidential election, John made the following racial slur: “I hate it that we now have a nigger in the White House!” Carole (herself white) was understandably taken aback and deeply offended that John would have thought to describe anyone in such an offensive manner. But, by summoning up every bit of empathy that she could possibly muster, Carole did somehow manage to respond with the following: “You are concerned about the direction in which our country is going.” This empathic utterance on Carole’s part enabled the session to continue; and John then went on to talk about his upset, anger, frustration, and despair about the direction in which he felt the country was going and, quite frankly, the direction in which he felt his own life was going. The session ended up being a very productive one. A price, however, had been paid. Although Carole had managed to

be empathic (which not only enabled the session to continue but also prompted John to delve more deeply into the heartfelt anguish and despair he was feeling about the course of his own life), Carole had been left with feelings of shock and revulsion; and despite the passage of time and Carole’s efforts to let it go, the souring of her feelings had persisted and Carole now found herself having a little less respect for John, feeling a little less affection for him, and becoming a little more withdrawn from him during their sessions. Nonetheless, the therapy continued to progress well; and John, in his life on the outside, was making substantial gains. And so it was that Carole’s empathic remark, although enabling John to feel understood, obviated the need for the two of them to address the dysfunctional relational dynamic (Carole’s overprotectiveness / John’s subsequent need to distance / Carole’s retreat) that was being played out between them and creating tension in their relationship. In 2012 Carole came to me for supervision (around John and various others in her clinical practice). In reviewing John’s case with me, Carole acknowledged the horror she still felt about the racial slur John had uttered those years earlier. In our supervision session, the idea suddenly came to me that perhaps Carole could use the upcoming November 2012 presidential election as an opportunity to re-visit what

had happened between the two of them in 2008. Right after the announcement was made that Obama had indeed been re-elected to the White House, Carole – despite the fact that John had not, this time, commented on the election results – opened the next session by saying that Obama’s re-election was reminding her of what John had said to her the first time Obama had won. Carole had decided not to share directly with John (at least not initially) what she had felt in response to his provocative remark. Rather, she simply asked “When you referred to Obama as a nigger, how were you imagining that I would respond?” The Rule of Three: Hoping, Fearing, Imagining

I believe that when a patient says or does something that the therapist experiences as provocative, the therapist has the option of asking the patient any of the following: (1) “How are you hoping that I will respond?” – which speaks to the patient’s id; (2) “How are you fearing that I might respond?” – which speaks to the patient’s superego; and (3) “How are you imagining that I will respond?” – which speaks to the patient’s ego (the executive functioning of his ego). All three questions demand of the patient that he make his interpersonal intentions more explicit – in essence, that he take responsibility for his provocative enactment.

In any event, at first John was clearly surprised by Carole’s question; but, to his credit, he did pause to reflect upon what he remembered of that moment between them those four years earlier. Interestingly, John did then go on to acknowledge that he had known all along that Carole would probably be offended by his remark. As Carole and John continued to explore at the intimate edge of their

relationship,

it

became

clear

that

Carole’s

hovering

overprotectiveness (during their earlier years and prior to John’s offputting 2008 remark) had indeed been experienced by John as somewhat intrusive and was probably at least in part responsible for what had then prompted him to make what he knew, in his heart of hearts, was a provocative and offensive remark about Obama to Carole. John also acknowledged that, in retrospect, he had felt a complex mixture of feelings after his distancing of Carole: some relief that he had actually succeeded in getting the distance he felt he needed; some shame about having said what he had in order to get that distance; and some sadness that the two of them were indeed no longer as close. It was in the context of their negotiating at their intimate edge that Carole also now admitted to having felt distanced and somewhat put-off by John’s offensive remark about Obama. She also went on to acknowledge her own sadness that the two of them had then become less connected.

As John and Carole continued to examine the mutual enactment that had taken place between them and together, with shared mind and shared heart, grieved the loss of the special connection that they had enjoyed during the earlier years of their relationship, they discovered a newer connection – one that was ultimately much more solid, honest, and genuine. John apologized to Carole for his insulting comment about Obama (adding that he was still no Obama fan!); and Carole graciously accepted the apology. Carole, in her turn, also apologized for having been too maternal in her approach to John during their earlier years and for not having found a way to share with him how taken aback she had been by his derogatory 2008 remark about Obama. At the end of the day, both John and Carole felt much better and much closer for having put more explicitly into words what each had been experiencing in relation to the other – both during the years prior to 2008 and during the four years between 2008 and 2012.

Clinical Vignette: The Capacity to Tolerate Ambivalence I present now another vignette that speaks to the distinction between an empathic response and an authentic response and highlights the importance of the therapist’s capacity to work through her countertransference in order to get to a place of being able to offer the

patient an analytically useful intervention. Kathy has been involved with Jim, a man who appears to be very attached to her but, nonetheless, periodically has affairs with other women. It is always devastating for Kathy when she finds out, but each time Jim resolves to do better in the future and Kathy takes him back. One day, however, Kathy discovers that Jim has had a one-night stand with someone she had considered to be her best friend. To her therapist, she reports her outrage that Jim would be doing this to her – yet again and with her best friend! Kathy tells her therapist that the relationship with Jim is definitely over. The therapist is easily able to be empathic with how Kathy feels. But it is much harder for the therapist to empathize when Kathy comes to the next session with a report that she and Jim have had a good talk and have reconciled; Kathy explains that Jim is beginning to see that he has a problem and has promised to get himself into therapy. Jim has told her that he feels awful about having done what he did and begs her forgiveness. The therapist, knowing that this is neither the first time Jim has promised to get himself into therapy nor the first time Jim has promised

things will change, finds herself feeling skeptical; she is also aware of feeling horrified that Kathy would actually be willing to give Jim yet another chance! To herself the therapist thinks, "Heavens, when is Kathy going to get it!? Jim is never going to give her what she wants. Why can't Kathy just let him go!?" The therapist considers the possibility of sharing with Kathy some of her sentiments (or, at least, a modified version of them); she decides, however, that for now her feelings are so raw and so unprocessed that she does not really trust herself to say something that would be therapeutically useful to Kathy, something that would further the therapeutic endeavor. And so the therapist decides to respond more empathically to Kathy by trying, as best she can, to decenter from her own feelings of outrage at Jim's provocative behavior and of horror at Kathy's refusal to confront that reality. The therapist therefore offers Kathy the following: "You are outraged and devastated by what Jim has done but want very much to believe that this time Jim has finally understood that his behavior is unacceptable. You are encouraged by his decision to enter therapy, and you are thinking that he is finally beginning to take some responsibility for his actions."

Clearly feeling understood and supported by the therapist's empathic recognition of where she is, Kathy responds with, "Jim makes me feel loved in a way that I have never before felt loved. He makes me feel very special, and that means a lot to me." Later, Kathy goes on to admit, "I do know that Jim could always do it again. He has done it many times in the past. But I guess I need to believe that this time he will come through for me. This time it will be different." The therapist's empathic response creates a space for Kathy within which she can feel safe enough, and nondefensive enough, that she can delve more deeply into acknowledging her need for Jim – that is, Kathy elaborates upon the positive side of her ambivalence about Jim. Later, she is able to get in touch with the negative side of that ambivalence, which she must be able to do if she is ultimately to work through her conflictedness about Jim. In other words, for Kathy to be able, in time, to let go of Jim, she must come to understand both the gain (that is, what investment she has in staying with Jim) and the pain (that is, what price she pays for refusing to let go). In order to understand the gain, Kathy must be given the space to elaborate upon the positive side of her ambivalence about Jim; in order to understand the pain, Kathy must get to a place of being able to recognize, and take ownership of, the negative side of her ambivalence

about Jim. The therapist's empathic response frees Kathy up to talk about how it serves her to be with Jim; once Kathy has had an opportunity to do this, she is then able, of her own accord and at her own pace, to let herself remember just how painful the relationship has been for her. Now had the therapist, instead of being empathic, been able to process her own feelings of outrage and horror a little more quickly, she might, alternatively, have used aspects of this experience to offer Kathy the following: "On the one hand I find myself feeling horrified that you would be willing to give Jim yet another chance (given how much he has hurt you), but then I think about how important it is for you to be able to feel loved (because of how unloved you always felt by your father) – and I think I begin to understand better why you might be willing to give him one more chance." The therapist, by bringing together both sides of her own ambivalent response to Kathy, is here offering herself as a container for Kathy's disavowed conflictedness. Although, in the moment, Kathy might have lost sight of the negative side of her ambivalence, the therapist is remembering and carrying (on Kathy's behalf) both sides of the ambivalence.

The Therapist Has Capacity Where the Patient Has Need We would say of the therapist that she has capacity where Kathy has need – the therapist has the capacity to sit with and to hold in mind simultaneously both sides of her ambivalence, whereas Kathy, in the moment, would seem to have the capacity to remember only the positive side of her ambivalence and the need not to remember the negative side. The therapist's capacity to tolerate what the patient finds intolerable is the hallmark of a successful projective identification. The therapist takes on Kathy's conflict and, after processing it psychologically, makes a modified version of it available to Kathy for reinternalization. In time, Kathy may well be able herself to acknowledge simultaneously both sides of her conflictedness – that is, both the gain and the pain.

How the Therapist Positions Herself As noted earlier, the empathic attunement of Model 2 requires of the therapist that she decenter from her own subjectivity in order to join alongside the patient; the therapist will then be able to enter into the patient’s experience and take it on, but only as if it were her own because it never actually becomes her own. The therapist, by remaining ever focused on, and attuned to, the patient’s moment-by-moment experience

will be able to resonate empathically with the patient’s experience, such that the patient will have the profoundly satisfying experience of being heard and understood – or, in the words of self psychology, validated. Empathic attunement is not about the therapist’s experience; it is about the patient’s experience. The authentic engagement of Model 3, however, requires of the therapist that she remain very much centered within her own subjectivity, the better to allow the patient’s experience to enter into her; the therapist, ever open to being impacted, will then take on the patient’s experience as her own, such that the therapist’s experience will come to be informed by both the there-and-then of the therapist’s early-on history and the here-and-now of the therapeutic engagement. The therapist, by remaining ever focused on, and attuned to, her own moment-by-moment experience, will then be able to lend aspects of her own capacity to a psychological processing and integrating of what she is experiencing as a result of being in relationship with the patient, such that the patient will have the profoundly healing experience of knowing that she is not alone, of knowing that someone else is present with her, of knowing that someone else is sharing her experience. Authentic engagement is not so much about the patient’s experience as it is about the sharing of experience between patient and therapist.

In essence, empathic attunement and authentic engagement represent different ways the therapist can position herself in relation to the patient. It is not that one approach is better than the other one or more evolved; rather, it is that these are two different, and complementary, approaches. By being empathic, the therapist will create certain possibilities for the unfolding of the therapeutic action – but at the expense of other options; by the same token, by being authentic, the therapist will create certain other possibilities for the unfolding of the therapeutic action – but at the expense of other options. I am here reminded of Robert Frost’s “The Road Not Taken” (2002). The therapist is continuously choosing one path over another, all the while knowing that in making the choices she is making she will never know where the other paths might have led.

How the Therapist Listens vs. How the Therapist Responds Parenthetically, it is important to keep in mind that there is a distinction between how the therapist listens and how the therapist then responds. In the first instance, we are speaking to how the therapist comes to know the patient; in the second instance, we are speaking to how the therapist, based upon what she has come to know, then intervenes. When a therapist is said to be empathic, it is therefore not clear whether the speaker is suggesting that the therapist is listening

empathically and/or responding empathically; what is meant, however, will usually be clear from the context. The important point to be made here is that a good therapist will listen simultaneously – even though paradoxically – with objectivity (Model 1), empathy (Model 2), and authenticity (Model 3). In other words, a good therapist will come to know the patient by focusing on neither the patient’s nor her own experience but on what she observes (Model 1), by focusing on the patient’s experience (Model 2), and by focusing on her own experience (Model 3). All three modes of listening will offer important information about the patient and the therapy relationship. How the therapist then decides to intervene will be a story about both what the therapist has come to know and how the therapist conceptualizes the ever-evolving therapeutic action – whether, in the moment, it involves primarily enhancement of knowledge within, provision of corrective experience for, or engagement in authentic relationship with. So how exactly do we conceive of the process by which patients are healed? In order to understand the therapeutic process, we will think about how the therapist positions herself moment by moment in relation

to the patient. My belief is that the position she assumes will affect both what she comes to know (afference) and how she then intervenes (efference).

How the Therapist Comes to Know With respect to how the therapist arrives at understanding of the patient, I contend that the most effective listening stance is one in which the therapist achieves an optimal balance between positioning herself as object, as selfobject, and as subject. (1) As a neutral object, the therapist positions herself outside the therapeutic field in order to observe the patient. Her focus is on the patient's internal dynamics. (2) As an empathic selfobject, the therapist joins alongside the patient in order to immerse herself in the patient's subjective reality. Her focus is on the patient's affective experience. (3) As an authentic subject, the therapist remains very much centered within her own experience – using that experience (in other words, the countertransference) to deepen her understanding of the patient. Her focus is on the here-and-now engagement between them.

To this point, the therapist is simply gathering information; she has not yet done anything with what she has come to know.

How the Therapist Then Intervenes With respect to how the therapist then intervenes, my belief is that the most effective interventive stance is one in which the therapist achieves an optimal balance between formulating interpretations, offering some form of corrective provision, and engaging interactively in relationship. (1) The therapist formulates interpretations with an eye to advancing the patient's knowledge of her internal dynamics. The ultimate goal is resolution of the patient's structural conflicts. (2) The therapist offers some form of corrective provision with an eye either to validating the patient's experience or, more generally, to providing the patient with a corrective experience. The ultimate goal is filling in the patient's structural deficits and consolidating the patient's self. (3) The therapist engages the patient interactively in relationship with an eye to advancing the patient's knowledge of her relational dynamics and/or to deepening the connection between the two of them.

The ultimate goal is resolution of the patient's relational difficulties and development of her capacity to engage healthily and authentically in relationship. With each patient, whatever her diagnosis, whatever her underlying psychodynamics, the optimal therapeutic stance is one that is continuously changing. In fact, moment-by-moment, the therapist's position shifts. The stance the therapist assumes is sometimes spontaneous and unplanned, sometimes more deliberate and considered. In other words, there are times when the therapist finds herself unwittingly drawn in to participating with the patient in a particular way because the intersubjective field has pulled for that form of participation. But there are other times when the therapist makes a more conscious choice, based on what she intuitively senses the patient most needs in the moment in order to heal. How the therapist decides to intervene, therefore, depends on both what she has come to understand about the patient by virtue of the listening position she has assumed and what she thinks the patient most needs – whether enhancement of knowledge, provision of experience, or engagement in relationship.

At any given point in time, the therapist is also profoundly affected by what had come before – in the moments leading up to the current moment. Past and present are always inextricably linked; no moment in time stands on its own. And so it is that how the therapist chooses to intervene in the moment depends also on what had transpired in the moments preceding. My intent is to provide the therapist with a way to conceptualize the options available to her as she sits with her patient – with respect both to how she arrives at understanding and to what she then does or says. I am offering not a prescription for what the therapist should do but rather a description of what the therapist already does do.

Knowledge, Experience, and Relationship In sum, I believe that the three modes of therapeutic action (knowledge, experience, and relationship) are not mutually exclusive but mutually enhancing. The conceptual framework I am offering here is a synthetic one that integrates three perspectives: (1) the interpretive perspective of classical psychoanalytic theory;

(2)

the

corrective-provision

(or

deficiency-compensation)

perspective of self psychology and those object relations theories emphasizing the absence of good; and (3) the relational (or interactive) perspective of contemporary psychoanalytic theory and those object relations theories emphasizing the presence of bad. The impetus for my effort to integrate the three models stems from my belief that none of the three is sufficient, on its own, to explain our clinical data or to guide our interventions. Although there is of course some overlap, each model contains elements lacking in the other two. Obviously, no model can begin to do justice by something this complex and multifaceted, but my hope is that the integrative model I am proposing will prompt therapists to become more aware of the choices they are continuously making about how they listen to the patient and how they then intervene. Whereas Model 1 is a one-person psychology and Model 2 is a oneand-a-half-person psychology, Model 3 is truly a two-person psychology. And whereas the Model 1 therapist is seen as a neutral object (whose focus is on the patient's internal process) and the Model 2

therapist is seen as an empathic selfobject or good object/good mother (whose focus is on the patient's moment-by-moment affective experience), the Model 3 therapist is seen as an authentic subject (whose focus is on the intimate edge between them). In Model 1, although the short-term goal is enhancement of knowledge, the ultimate goal is resolution of structural conflict. In Model 2, although the immediate goal is provision of (corrective) experience, the long-range goal is filling in of structural deficit. In Model 3, although the short-term goal is engagement in relationship (and a deepening of connection between patient and therapist), the ultimate goal is development of capacity for healthy, authentic relatedness. And, finally, whereas Model 2 is about offering the patient an opportunity to find a new good object – so that there can be restitution, Model 3 is about offering the patient an opportunity to re-find the old bad one – so that the traumatogenic early-on interactions can be worked through in the context of the patient's here-and-now engagement with the therapist. Along these same lines, Greenberg (1986) has suggested that if the therapist does not participate as a new good object, the therapy never gets under way; and if she does not participate as the old bad one, the

therapy never ends – which captures exquisitely the delicate balance between the therapist's participation as a new good object (so that there can be a new beginning) and the therapist's participation as the old bad object (so that there can be an opportunity to achieve belated mastery of the internalized traumas). Indeed, psychoanalysis has come a long way since the early days when Freud was emphasizing the importance of sex and aggression. No longer is the spotlight on the patient's drives (and their vicissitudes); now the spotlight is on the patient's relationships (and their vicissitudes). And where once psychoanalysis focused on the relationship that exists between structures within the psyche of the patient, contemporary psychoanalysis focuses more on the relationship that exists between the patient and her objects – or, more accurately, the intersubjective relationship that exists between the patient and her subjects. In Benjamin's (1988) words: "...where objects were, subjects must be" (p. 44).

Conclusion I am proposing that the repertoire of the contemporary therapist includes formulating interpretations, offering some form of corrective provision, and engaging interactively in a relationship that is reciprocally

mutual. I think that the most therapeutically effective stance is one in which the therapist is able to achieve an optimal balance between (a) positioning herself outside the therapeutic field (in order to formulate interpretations about the patient and her internal process so as to facilitate resolution of the patient's structural conflict), (b) decentering from her own experience (in order to offer the patient some form of corrective provision so as to facilitate the filling in of the patient's structural deficit), and (c) remaining very much centered within her own experience (in order to engage authentically with the patient in a real relationship so as to facilitate resolution of the patient's relational difficulties). Casement (1985), in speaking to how the therapist positions himself optimally in relation to the patient, suggests the following: The therapist must "learn how to remain close enough to what the patient is experiencing" to be able to be affected by the patient – “while preserving a sufficient distance" to function as therapist. "But that professional distance should not leave him beyond the reach of what the patient may need him to feel. A therapist has to discover how to be psychologically intimate with a patient and yet separate, separate and still intimate" (p. 30).

In the language we have been using here, the therapist must empathically join the patient where she is even as the therapist preserves her distance so that she can still function interpretively. But the therapist should never be so far away that the patient cannot find her and engage her authentically. Intimate without losing the self, separate without losing the other. It will be a challenge for any therapist to attempt to hold in mind, simultaneously, the three different perspectives without pulling for premature closure – closure that may ease the therapist's anxiety but will probably limit the realm of therapeutic possibilities. The most effective therapists will be those who (a) manage somehow to tolerate – perhaps, even, for extended periods of time – the experience of not knowing or, in Bollas's (1989) words, the experience of necessary uncertainty; (b) are open to being shaped by the patient's need and by whatever else might arise within the context of their intersubjective relationship; and, more generally, (c) are willing to bring the best of themselves, the worst of themselves, and the most of themselves into the room with the patient – so that each will have the opportunity to find the other.

References Balint, M. 1992. The basic fault: Therapeutic aspects of regression. New York and London: Routledge, 2nd ed.

Buber, M. 1966. Tales of the Hasidim: The early masters. New York: Schocken. Casement, P. 1985. Forms of interactive communication. In On learning from the patient, 72101. London and New York: Tavistock. Ehrenberg, D. 1992. The intimate edge: Extending the reach of psychoanalytic interaction. New York: W.W. Norton & Co. Fairbairn, W.R.D. 1963. Synopsis of an object relations theory of personality. Int J Psychoanal 44:224-255. Freud, S. 1923. The ego and the id. New York: W.W. Norton & Co. ----- 1937. Analysis terminable and interminable. Int J Psycho-Anal 18:373-405. Greenberg, J.R. 1986. The problem of analytic neutrality. Contemp Psychoanal 22:76-86. Hoffman, I. 1983. The patient as interpreter of the analyst’s experience. Contemp Psychoanal 19:389-422. Kohut, H. 1966. Forms and transformations of narcissism. J Am Psychoanal Assoc 14(2):243272. ----- 1984. How does analysis cure? Chicago: University of Chicago Press. Malin, A. and Grotstein, J. 1966. Projective identification in the therapeutic process. Int J Psychoanal 47:26-31. Mitchell, S. 1988. Relational concepts in psychoanalysis: An integration. Cambridge, MA: Harvard University Press. Morrison, A. 1997. Shame: The underside of narcissism. Berkeley, CA: The Analytic Press. Ornstein, P. 1974. On narcissism: Beyond the introduction – highlights of Kohut’s contribution to the psychoanalytic treatment of narcissistic personality disorders. Annual Psychoanal 2:127-149.

Renik, O. 1993. Analytic interaction: Conceptualizing technique in light of the analyst’s irreducible subjectivity. Psychoanal Q 62(4):553-571. Stark, M. 1994a. Working with resistance. Northvale, NJ: Jason Aronson. ----- 1994b. A primer on working with resistance. Northvale, NJ: Jason Aronson. ----- 1999. Modes of therapeutic action: Enhancement of knowledge, provision of experience, and engagement in relationship. Northvale, NJ: Jason Aronson. ----- 2008. Hormesis, adaptation, and the sandpile model. Crit Rev Toxicol 38(7):641-644. ----- 2012. The sandpile model: Optimal stress and hormesis. Dose Response 10(1):66-74. ----- 2014. Optimal stress, psychological resilience, and the sandpile model. In Hormesis in health and disease, ed. S. Rattan and E. Le Bourg, 201-224. Boca Raton: CRC Press/Taylor & Francis. ----- 2015. Integrative psychotherapy: Healing the MindBodyMatrix. In Integrative therapies for depression: Redefining models for assessment, treatment, and prevention, ed. J.M. Greenblatt and K. Brogan. Boca Raton: CRC Press/Taylor & Francis. Winnicott, D.W. 1960. The theory of the parent-infant relationship. Int J Psycho-Anal 41:585-595. ----- 1990. The maturational processes and the facilitating environment. UK, London: Karnac Books. Zevon, W. 1996. I’ll sleep when I’m dead. Burbank, CA: Elektra Records.

Part 2

Module 1

THE HEALING PROCESS AND

TRANSFORMATION OF DEFENSE INTO ADAPTATION

OVERVIEW

THE THERAPEUTIC PROCESS FROM CURSING THE DARKNESS TO LIGHTING A CANDLE FROM DEFENSE TO ADAPTATION

DEFENSES DYSFUNCTIONAL / PRIMITIVE / REFLEXIVE / UNHEALTHY RIGID / LOW – LEVEL / UNEVOLVED ARE NEEDED FOR THE SYSTEM TO SURVIVE BUT ARE VERY COSTLY IN TERMS OF THE SYSTEM’S FUNCTIONALITY

ADAPTATIONS MORE FUNCTIONAL / MORE COMPLEX / REFLECTIVE / HEALTHIER MORE FLEXIBLE / HIGHER – LEVEL / MORE EVOLVED ENABLE THE SYSTEM TO THRIVE BUT ARE ULTIMATELY COSTLY IN TERMS OF THE SYSTEM’S RESERVES

ALTHOUGH DEFENSES ARE GENERALLY LESS HEALTHY AND LESS EVOLVED AND ADAPTATIONS MORE HEALTHY AND MORE EVOLVED, BOTH ARE SELF – PROTECTIVE MECHANISMS THAT SPEAK TO THE LENGTHS TO WHICH A SYSTEM WILL GO IN ORDER TO PRESERVE ITS HOMEOSTATIC BALANCE IN THE FACE OF ENVIRONMENTAL CHALLENGE BE THAT CHALLENGE EXTERNALLY OR INTERNALLY DERIVED PSYCHOLOGICAL, PHYSIOLOGICAL, OR ENERGETIC IN TRUTH

DEFENSES AND ADAPTATIONS ARE FLIP SIDES OF THE SAME COIN DEFENSES ALWAYS HAVE AN ADAPTIVE FUNCTION JUST AS ADAPTATIONS DO ALSO SERVE TO DEFEND

IN OTHER WORDS

DEFENSES AND ADAPTATIONS HAVE A YIN AND YANG RELATIONSHIP, REPRESENTING, AS THEY DO, NOT OPPOSING BUT COMPLEMENTARY FORCES FOR EXAMPLE, SHADOW CANNOT EXIST WITHOUT LIGHT IN FACT

JUST AS IN QUANTUM THEORY WHERE PARTICLES AND WAVES ARE THOUGHT TO BE DIFFERENT MANIFESTATIONS OF A SINGLE REALITY DEPENDING UPON THE OBSERVER’S PERSPECTIVE

SO TOO DEFENSE AND ADAPTATION ARE CONJUGATE PAIRS DEMONSTRATING THIS SAME DUALITY

“BOTH – AND” NOT “EITHER – OR”

THE DISTINCTION IS HERE BEING MADE BETWEEN DEFENSIVE REACTIONS THAT ARE MOBILIZED IN THE IMMEDIATE AFTERMATH OF CHALLENGE AND ARE AUTOMATIC, KNEE – JERK, STEREOTYPIC, AND RIGID AND ADAPTIVE RESPONSES THAT UNFOLD IN THE AFTERMATH OF CHALLENGE ONLY OVER TIME AND ARE THEREFORE MORE PROCESSED, INTEGRATED, FLEXIBLE, AND COMPLEX

THE THERAPEUTIC PROCESS WILL THEREFORE INVOLVE THE TRANSFORMATION OF UNHEALTHY AND UNEVOLVED DEFENSE INTO HEALTHIER AND MORE EVOLVED ADAPTATION DEFENSIVE REACTION INTO ADAPTIVE RESPONSE DEFENSIVE NEED INTO ADAPTIVE CAPACITY BY WAY OF EXAMPLES

THE NEED FOR IMMEDIATE GRATIFICATION INTO THE CAPACITY TO TOLERATE DELAY THE NEED FOR PERFECTION INTO THE CAPACITY TO TOLERATE IMPERFECTION THE NEED FOR EXTERNAL REGULATION OF THE SELF INTO THE CAPACITY TO BE INTERNALLY SELF – REGULATING THE NEED TO HOLD ON INTO THE CAPACITY TO LET GO

IN ESSENCE, FROM CURSING THE DARKNESS TO LIGHTING A CANDLE

A POEM THAT SPEAKS DIRECTLY TO A SYSTEM’S CAPACITY TO ADAPT TO STRESSFUL INPUT

COME TO THE EDGE. WE MIGHT FALL. COME TO THE EDGE. IT’S TOO HIGH! COME TO THE EDGE! AND THEY CAME, AND HE PUSHED, AND THEY FLEW … (LOGUE 2004)

MY GOAL HAS LONG BEEN TO CREATE

A CONCEPTUAL FRAMEWORK THAT CAPTURES THE ESSENCE OF THE PROCESS OF HEALING

BE IT OF THE MIND OR OF THE BODY TO THAT END

I HAVE DEVELOPED THE TERM MindBodyMatrix A CONCEPT THAT REFLECTS A KEEN APPRECIATION FOR THE INTIMATE AND PRECISE RELATIONSHIP THAT EXISTS BETWEEN THE HEALTH AND VITALITY OF THE MIND AND THAT OF THE BODY (STARK 2008, 2012, 2014, 2015)

AS I HAVE EVOLVED OVER THE COURSE OF THE DECADES, SO TOO MY UNDERSTANDING OF THE HEALING PROCESS HAS EVOLVED – FROM ONE THAT EMPHASIZES THE INTERNAL WORKINGS OF THE MIND TO ONE THAT IS MORE HOLISTIC AND RECOGNIZES THE COMPLEX INTERDEPENDENCE OF MIND AND BODY

LONG INTRIGUING TO ME HAS BEEN THE IDEA THAT SUPERIMPOSING AN ACUTE PHYSICAL INJURY ON TOP OF A CHRONIC ONE IS SOMETIMES EXACTLY WHAT THE BODY NEEDS IN ORDER TO HEAL OVER TIME I HAVE COME TO BELIEVE THAT

SO TOO SUPPLEMENTING AN EMPATHICALLY ATTUNED AND AUTHENTICALLY ENGAGED THERAPY RELATIONSHIP WITH “OPTIMALLY STRESSFUL” PSYCHOTHERAPEUTIC INTERVENTIONS SPECIFICALLY DESIGNED “TO PRECIPITATE DISRUPTION IN ORDER TO TRIGGER REPAIR”

WILL SOMETIMES BE THE MAGIC INGREDIENT NEEDED TO OVERCOME THE INHERENT RESISTANCE TO CHANGE SO FREQUENTLY ENCOUNTERED IN OUR PATIENTS WITH LONGSTANDING EMOTIONAL INJURIES AND SCARS

FOR EXAMPLE

THE PRACTICE OF WOUND DEBRIDEMENT TO ACCELERATE HEALING SPEAKS DIRECTLY TO THIS CONCEPT OF

CONTROLLED DAMAGE NOT ONLY DOES DEBRIDEMENT PREVENT INFECTION BY REMOVING FOREIGN MATERIAL AND DAMAGED TISSUE FROM THE SITE OF THE WOUND BUT ALSO IT PROMOTES HEALING BY MILDLY AGGRAVATING THE AREA, WHICH WILL IN TURN JUMPSTART THE BODY’S INNATE ABILITY TO SELF – HEAL IN THE FACE OF CHALLENGE

ANOTHER EXAMPLE OF CAUSING PHYSICAL IRRITATION OR INJURY TO PROVOKE RECOVERY IS THE PRACTICE OF PROLOTHERAPY THIS TECHNIQUE IS A HIGHLY EFFECTIVE TREATMENT FOR CHRONIC WEAKNESS AND PAIN IN SUCH VULNERABLE AREAS AS THE LOWER BACK, SHOULDER, HIP, AND KNEE IN ORDER TO ACTIVATE THE BODY’S HEALING CASCADE, A MILDLY IRRITATING AQUEOUS SOLUTION FOR EXAMPLE, A RELATIVELY INNOCUOUS SUBSTANCE LIKE DEXTROSE, A LOCAL ANESTHETIC LIKE LIDOCAINE, AND WATER

IS INJECTED INTO THE AFFECTED LIGAMENT OR TENDON, RESULTING ULTIMATELY IN OVERALL STRENGTHENING OF THE DAMAGED CONNECTIVE TISSUE AND ALLEVIATION OF THE PAIN

PROLOTHERAPY IS BELIEVED BY FORWARD – THINKING PRACTITIONERS TO BE SIGNIFICANTLY MORE EFFECTIVE THAN CORTISONE INJECTIONS BECAUSE THESE LATTER TREATMENTS ALTHOUGH SOMETIMES ABLE TO PROVIDE IMMEDIATE SHORT – TERM RELIEF OF PAIN

WILL CAUSE DESTRUCTION OF TISSUE AND EXACREBATION OF PAIN OVER THE LONG HAUL BECAUSE OF THEIR CATABOLIC OR BREAKDOWN

EFFECT

ALONG THESE SAME LINES BUT NOW SHIFTING FROM BODY TO MIND

IT TOOK ME YEARS TO APPRECIATE SOMETHING ABOUT THE PSYCHOTHERAPEUTIC PROCESS THAT IS AT ONCE BOTH COMPLETELY OBVIOUS AND QUITE PROFOUND NAMELY

THAT IT WILL BE INPUT FROM THE OUTSIDE AND THE PATIENT’S CAPACITY TO PROCESS, INTEGRATE, AND ADAPT TO THIS INPUT THAT WILL ULTIMATELY ENABLE THE PATIENT TO CHANGE

ONLY MORE RECENTLY, HOWEVER, HAVE I HAVE COME TO UNDERSTAND THAT

THE PATIENT MAY NEED SOMETHING MORE THAN SIMPLY INPUT FROM THE OUTSIDE IN ORDER TO CHANGE INDEED

IT MAY WELL BE ONLY STRESSFUL INPUT FROM THE OUTSIDE AND THE PATIENT’S CAPACITY TO PROCESS, INTEGRATE, AND ADAPT TO THE IMPACT OF THIS STRESSFUL INPUT

THAT WILL PROMPT THE PATIENT TO CHANGE

IN OTHER WORDS

IT IS NOT SO MUCH GRATIFICATION AS FRUSTRATION AGAINST A BACKDROP OF GRATIFICATION OPTIMAL FRUSTRATION

NOT SO MUCH SUPPORT AS CHALLENGE AGAINST A BACKDROP OF SUPPORT NOT SO MUCH EMPATHY AS EMPATHIC FAILURE AGAINST A BACKDROP OF EMPATHY

THAT WILL PROVIDE THE THERAPEUTIC LEVERAGE NEEDED TO PROVOKE AFTER INITIAL DESTABILIZATION

EVENTUAL RESTABILIZATION AT A HIGHER LEVEL OF FUNCTIONALITY AND ADAPTIVE CAPACITY

MORE SPECIFICALLY

IF THERE IS NO THWARTING OF DESIRE THAT IS, NO OBSTACLE TO BE OVERCOME

THEN THERE WILL BE NOTHING THAT NEEDS TO BE MASTERED AND THEREFORE NO REAL IMPETUS FOR TRANSFORMATION AND GROWTH

BEHIND THIS “NO PAIN / NO GAIN” APPROACH IS MY FIRM BELIEF IN THE UNDERLYING RESILIENCE THAT PATIENTS WILL INEVITABLY DISCOVER WITHIN THEMSELVES ONCE THEY ARE FORCED TO TAP INTO THEIR INBORN ABILITY TO SELF – CORRECT IN THE FACE OF ENVIRONMENTAL CHALLENGE WHICH SPEAKS TO THE WISDOM OF THE BODY (CANNON 1932)

AN INNATE CAPACITY THAT WILL ULTIMATELY ENABLE THEM TO ADVANCE FROM LESS – EVOLVED DEFENSIVE REACTION TO MORE – EVOLVED ADAPTIVE RESPONSE

Module 2

CHAOS THEORY AND

PSYCHIC INERTIA

WHY IS IT THAT PEOPLE KEEP PLAYING OUT THE SAME SCENARIOS IN THEIR LIVES OVER AND OVER AGAIN EVEN WHEN THEY KNOW THAT THE OUTCOME WILL BE JUST AS DISAPPOINTING THIS TIME AS IT WAS THE TIME BEFORE? ALBERT EINSTEIN CAPTURES BEAUTIFULLY THE ESSENCE OF THESE UNCONSCIOUS RE – ENACTMENTS – “INSANITY IS DOING THE SAME THING OVER AND OVER AGAIN AND EXPECTING DIFFERENT RESULTS.”

INDEED

PERHAPS PART OF BEING HUMAN IS THAT WE WILL SO OFTEN FIND OURSELVES DOING THAT WHICH WE KNOW WE OUGHT NOT TO BE DOING AND NOT DOING THAT WHICH WE KNOW WE OUGHT TO BE DOING

AUTOBIOGRAPHY IN 5 SHORT CHAPTERS by Portia Nelson

CHAPTER 1 I WALK DOWN THE STREET THERE IS A DEEP HOLE IN THE SIDEWALK I FALL IN I AM LOST … I AM HELPLESS IT ISN’T MY FAULT IT TAKES FOREVER TO FIND A WAY OUT

CHAPTER 2 I WALK DOWN THE SAME STREET THERE IS A DEEP HOLE IN THE SIDEWALK I PRETEND I DON’T SEE IT I FALL IN AGAIN I CAN’T BELIEVE I AM IN THE SAME PLACE BUT IT ISN’T MY FAULT IT STILL TAKES A LONG TIME TO GET OUT

AUTOBIOGRAPHY IN 5 SHORT CHAPTERS by Portia Nelson

CHAPTER 3 I WALK DOWN THE SAME STREET THERE IS A DEEP HOLE IN THE SIDEWALK I SEE IT IS THERE I STILL FALL IN … IT’S A HABIT MY EYES ARE OPEN I KNOW WHERE I AM IT IS MY FAULT I GET OUT IMMEDIATELY

CHAPTER 4 I WALK DOWN THE SAME STREET THERE IS A DEEP HOLE IN THE SIDEWALK I WALK AROUND IT

CHAPTER 5 I WALK DOWN ANOTHER STREET

I AM HERE REMINDED OF

A SATURDAY NIGHT LIVE SKIT IN WHICH TWO MEN ARE SITTING AROUND A FIRE CHATTING AND ONE SAYS TO THE OTHER – “YOU KNOW HOW WHEN YOU STICK A POKER IN THE FIRE AND LEAVE IT IN FOR A LONG TIME, IT GETS REALLY, REALLY HOT? AND THEN YOU STICK IT IN YOUR EYE, AND IT REALLY, REALLY HURTS? I HATE IT WHEN THAT HAPPENS! I JUST HATE IT WHEN THAT HAPPENS!”

A POPULAR SONG THAT SPEAKS TO THE NEED SO MANY OF US HAVE TO RECREATE THAT WITH WHICH WE ARE MOST FAMILIAR AND THEREFORE MOST COMFORTABLE IS A ROCK SONG BY THE LATE WARREN ZEVON (1996) ENTITLED “IF YOU WON’T LEAVE ME I’LL FIND SOMEBODY WHO WILL”

THE REPETITION COMPULSION SPEAKS TO THE TENDENCY TO RE – ENACT THE SAME DYSFUNCTIONAL SCENARIOS AGAIN AND AGAIN

ON THE STAGE OF ONE’S LIFE SCENARIOS THAT ARE BOTH SELF – INDULGENT AND SELF – DESTRUCTIVE

THIS CONCEPT SPEAKS TO THE HOPE THAT SPRINGS ETERNAL IN ALL OF US – THE HOPE THAT PERHAPS, THIS NEXT TIME, THERE WILL BE A DIFFERENT OUTCOME, A BETTER RESOLUTION “RELENTLESS HOPE”

(STARK 1994) THE REFUSAL TO CONFRONT – AND GRIEVE – INTOLERABLY PAINFUL REALITIES ESPECIALLY WITH RESPECT TO THE OBJECTS OF OUR DESIRE

WE TURN NOW TO CHAOS THEORY TO INFORM OUR UNDERSTANDING OF WHAT FUELS PSYCHIC INERTIA AND THE RESISTANCE TO CHANGE IN CERTAIN SCIENTIFIC CIRCLES

PEOPLE ARE NOW BEING DESCRIBED AS COMPLEX ADAPTIVE, SELF – ORGANIZING CHAOTIC SYSTEMS COMPLEX – THE INTRICATE INTERDEPENDENCE OF THE SYSTEM’S COMPONENTS ADAPTIVE – THE CAPACITY TO LEARN FROM EXPERIENCE BY ADAPTING AND NOT JUST BY DEFENDING SELF – ORGANIZING – THE SPONTANEOUS EMERGENCE OF SYSTEM – WIDE PATTERNS ARISING FROM THE INTERPLAY OF THE SYSTEM’S COMPONENTS CHAOTIC – AN UNDERLYING ROBUST ORDEREDNESS THAT WILL EMERGE OVER TIME AS THE SYSTEM EVOLVES DESPITE THE SYSTEM’S APPARENT RANDOMNESS

AS I WILL SOON HOPE TO DEMONSTRATE

IT IS ALSO USEFUL TO CONCEIVE OF THE THERAPEUTIC PROCESS ITSELF AS A SELF – ORGANIZING (CHAOTIC) SYSTEM CHARACTERIZED BY THE EMERGENCE OF PATTERNS NAMELY, HEALING CYCLES OF DISRUPTION FOLLOWED BY REPAIR AT EVER – HIGHER LEVELS OF AWARENESS, ACCEPTANCE, AND ACCOUNTABILITY

AS THE TREATMENT EVOLVES

EXAMPLES OF SELF – ORGANIZING (CHAOTIC) SYSTEMS WHEREBY ORDER EMERGES FROM CHAOS AS THE SYSTEM EVOLVES CRYSTALLIZATION – THE SPONTANEOUS EMERGENCE OF BEAUTIFULLY PATTERNED CRYSTALS FROM SOLUTIONS OF RANDOMLY MOVING MOLECULES THE ASSEMBLAGE OF RIPPLED DUNES FROM GRAINS OF SAND THE GENERATION OF SWIRLING SPIRAL PATTERNS IN HURRICANES THE PHENOMENON WHEREBY THOUSANDS OF FIREFLIES GATHERED IN TREES AT NIGHT AND FLASHING ON AND OFF RANDOMLY WILL BEGIN TO FLASH IN UNISON A DRAMATIC ILLUSTRATION OF THE PHASE – LOCKING OF BIORHYTHMS

THE PHENOMENON WHEREBY FEMALE ROOMMATES WILL BEGIN TO MENSTRUATE ON THE SAME CYCLE THE PHENOMENON WHEREBY A NUMBER OF GRANDFATHER CLOCKS WITH THEIR PENDULUMS INITIALLY SWINGING RANDOMLY WILL EVENTUALLY ENTRAIN, SUCH THAT ALL THE PENDULUMS WILL BE SWINGING IN PRECISE SYNCHRONY (BENTOV 1988) NEURAL NETWORKS, FASHION TRENDS, THE STOCK MARKET, TRAFFIC JAMS

CHAOS THEORY CONCEIVES OF SELF – ORGANIZATION AS INVOLVING ISLANDS OF PREDICTABILITY AMIDST A SEA OF CHAOTIC UNPREDICTABILITY

NO MATTER HOW DYSFUNCTIONAL THEY MIGHT BE

SELF – ORGANIZING SYSTEMS FUELED AS THEY ARE BY THEIR HOMEOSTATIC TENDENCY TO REMAIN CONSTANT OVER TIME

RESIST PERTURBATION

(KREBS 2013)

HOW IS THIS RELEVANT FOR THE WORK WE DO?

PATIENTS MUST BE SUFFICIENTLY “STRESSED” BY INPUT FROM THE OUTSIDE THAT IS, BY OPTIMALLY STRESSFUL INTERVENTIONS THAT ARE ANXIETY – PROVOKING BUT ULTIMATELY GROWTH – PROMOTING

THAT THERE WILL BE IMPETUS THAT IS, FORCE NEEDED TO BRING ABOUT CHANGE

FOR THE (DYSFUNCTIONAL) STATUS QUO TO BE DESTABILIZED

TO EXPEDITE ADVANCEMENT OF THE PATIENT FROM IMPAIRED CAPACITY TO MORE ROBUST CAPACITY FROM COMPROMISED HEALTH TO A STATE OF WELL – BEING

THE THERAPIST MUST ALTERNATELY AND REPEATEDLY CHALLENGE THE PATIENT TO PRECIPITATE DISRUPTION

AND THEN SUPPORT THE PATIENT TO CREATE OPPORTUNITY FOR REPAIR ALL WITH AN EYE TO TAPPING INTO THE PATIENT’S INNATE STRIVING TOWARDS HEALTH AND INTRINSIC ABILITY TO SELF – CORRECT IN THE FACE OF OPTIMAL STRESS

THE NET RESULT OF WHICH WILL BE THE THERAPEUTIC INDUCTION OVER TIME

OF HEALING CYCLES OF DISRUPTION AND REPAIR DESTABILIZATION AND RESTABILIZATION DEFENSIVE COLLAPSE AND ADAPTIVE RECONSTITUTION

AT EVER – HIGHER LEVELS OF RESILIENCE AND VITALITY INDEED

THE PATIENT’S JOURNEY FROM ILLNESS TO WELLNESS WILL INVOLVE PROGRESSION THROUGH THESE ITERATIVE CYCLES AS THE PATIENT EVOLVES FROM CHAOS AND DYSFUNCTION TO COHERENCE AND FUNCTIONALITY

“THE WORLD BREAKS EVERYONE, AND AFTERWARD, MANY ARE STRONG AT THE BROKEN PLACES.” (HEMINGWAY 1929)

“THAT WHICH DOES NOT KILL US MAKES US STRONGER.” (NIETZSCHE 1899)

STRESS IS WHEN YOU WAKE UP SCREAMING AND THEN YOU REALIZE YOU HAVEN’T FALLEN ASLEEP YET ANONYMOUS

Module 3

THE GOLDILOCKS PRINCIPLE AND

CONTROLLED DAMAGE

STRESSFUL STUFF HAPPENS BUT IT WILL BE HOW WELL THE PATIENT IS ABLE TO PROCESS, INTEGRATE, AND ULTIMATELY ADAPT TO ITS IMPACT PSYCHOLOGICALLY, PHYSIOLOGICALLY, AND ENERGETICALLY

THAT WILL MAKE OF IT EITHER A GROWTH – DISRUPTING EVENT THAT OVERWHELMS BECAUSE IT IS “TOO MUCH” OR

A GROWTH – PROMOTING OPPORTUNITY THAT TRIGGERS TRANSFORMATION AND RENEWAL

STRESSFUL STUFF HAPPENS ALL THE TIME BUT IT WILL BE HOW WELL THE PATIENT IS ULTIMATELY ABLE TO MANAGE ITS IMPACT THAT WILL MAKE ALL THE DIFFERENCE IN OTHER WORDS

IT WILL BE HOW WELL THE PATIENT IS ULTIMATELY ABLE TO COPE WITH THE IMPACT OF STRESS IN HER LIFE THAT WILL EITHER DISRUPT HER GROWTH BY COMPROMISING HER FUNCTIONALITY OR TRIGGER HER GROWTH BY FORCING HER TO EVOLVE TO A HIGHER LEVEL OF ADAPTIVE CAPACITY

THE GOLDILOCKS PRINCIPLE THE PATIENT WILL FIND HERSELF REACTING / RESPONDING IN ANY ONE OF THREE WAYS TO THE THERAPIST’S STRESSFUL INPUT

TOO MUCH STRESS / CHALLENGE / ANXIETY WILL BE TOO OVERWHELMING FOR THE PATIENT TO PROCESS AND INTEGRATE, TRIGGERING INSTEAD DEFENSIVE COLLAPSE AND AT LEAST TEMPORARY DERAILMENT OF THE THERAPEUTIC PROCESS

TRAUMATIC STRESS TOO LITTLE STRESS / CHALLENGE / ANXIETY WILL PROVIDE TOO LITTLE IMPETUS FOR TRANSFORMATION AND GROWTH BECAUSE THERE WILL BE NOTHING THAT NEEDS TO BE MASTERED

TOO LITTLE STRESS WILL SERVE SIMPLY TO REINFORCE THE (DYSFUNCTIONAL) STATUS QUO

THE GOLDILOCKS PRINCIPLE AND OPTIMAL STRESS BUT JUST THE RIGHT AMOUNT OF STRESS / CHALLENGE / ANXIETY TO WHICH THE FATHER OF STRESS, HANS SELYE (1974, 1978), REFERRED AS EUSTRESS AND TO WHICH I (2008, 2012, 2014, 2015) REFER AS

“OPTIMAL STRESS” WILL OFFER JUST THE RIGHT COMBINATION OF CHALLENGE AND SUPPORT NEEDED TO OPTIMIZE THE POTENTIAL FOR TRANSFORMATION AND GROWTH LIKE THE THREE BOWLS OF PORRIDGE SAMPLED BY GOLDILOCKS, SO TOO THE DOSE OF STRESS PROVIDED BY THE THERAPIST WILL BE EITHER TOO MUCH, TOO LITTLE, OR JUST RIGHT

OUR FOCUS HERE WILL BE THE THERAPEUTIC USE OF OPTIMAL STRESS TO PROVOKE RECOVERY BY ACTIVATING THE LIVING SYSTEM’S INNATE ABILITY TO HEAL ITSELF

PARENTHETICALLY

OPTIMAL STRESS CAN ALSO BE USED TO FINE – TUNE THE FUNCTIONALITY OF AN ALREADY WELL – FUNCTIONING SYSTEM AND TO SLOW THE PROGRESSION OF AGE – RELATED DECLINE IN FUNCTIONALITY

INDEED

OPTIMAL CHALLENGE OF THE BRAIN WILL SERVE TO SHARPEN MENTAL ACUITY, TO DECELERATE COGNITIVE DECLINE, AND TO COMBAT THE EFFECTS OF AGING ON THE BRAIN JUST AS ATHLETES CAN IMPROVE THEIR PHYSICAL FITNESS BY OPTIMALLY CHALLENGING THEIR BODIES WITH PHYSICAL EXERCISE FOR EXAMPLE, HIGH – INTENSITY INTERVAL TRAINING (HIIT)

SO TOO ALL OF US CAN IMPROVE OUR BRAIN FITNESS BY OPTIMALLY CHALLENGING OUR MINDS WITH BRAIN TEASERS FOR EXAMPLE, MATHEMATICAL PUZZLES, WORD GAMES, CROSSWORD PUZZLES, LOGIC PROBLEMS, AND MEMORY CHALLENGES

ANY MENTAL EXERCISE REQUIRING DELIBERATE AND CONCENTRATED EFFORT FOR EXAMPLE, ACTIVE REPETITION, FOCUSED ATTENTION, LEARNING A NEW SKILL OR A NEW LANGUAGE, REFLECTION, OR MEDITATION

WILL PROMOTE MENTAL AGILITY AND DELAY THE DECLINE IN MENTAL CAPACITY AS WE AGE

IN ADDITION TO PUZZLES AND GAMES, OUR BRAINS WILL BE STIMULATED WHEN WE ARE EXPOSED TO SITUATIONS THAT ARE NEW, UNUSUAL, DIFFERENT, NOVEL, OR UNEXPECTED WHEN OUR DAILY ROUTINES ARE DISRUPTED OR WHEN WE COMBINE TWO SENSES LIKE LISTENING TO MUSIC AND SMELLING FLOWERS OR WATCHING A SUNSET AND TAPPING OUR FINGERS

EXERCISING MORE THAN ONE SENSE AT A TIME IS A FORM OF CROSS – TRAINING FOR THE BRAIN BECAUSE IT TAPS INTO THE BRAIN’S INHERENT TENDENCY TO FORM ASSOCIATIONS BETWEEN DIFFERENT TYPES OF INFORMATION

WHEREAS ROUTINE ACTIVITY CAN DEADEN THE BRAIN FOR EXAMPLE, DOING THE SAME THING DAY IN AND DAY OUT

SPICING THINGS UP BY INTRODUCING VARIETY INTO ONE’S DAILY ROUTINES CAN PROVIDE THE OPTIMALLY STRESSFUL CHALLENGE NEEDED TO ACTIVATE UNDERUSED NEURAL PATHWAYS AND CONNECTIONS, THEREBY MAKING THE BRAIN MORE FIT AND FLEXIBLE

IN ESSENCE

OPTIMAL CHALLENGE OF THE MIND PROMOTES NEUROPLASTICITY THE BRAIN’S AMAZING ABILITY TO ADAPT BY REORGANIZING, REPAIRING, AND RESTRUCTURING ITSELF

IN SUM

THE THERAPEUTIC VALUE OF CONTROLLED DAMAGE WHETHER PHYSICAL OR MENTAL AN APPROACH SPECIFICALLY GEARED TOWARDS MOBILIZING THE BODY’S INTRINSIC ABILITY TO RENEW ITSELF

A CONDITION MIGHT NOT HEAL UNTIL IT IS MADE ACUTE THUS THE BENEFIT OF SUPERIMPOSING AN ACUTE INJURY ON TOP OF A CHRONIC ONE

MILD AGGRAVATIONS CAN STIMULATE THE HEALING CASCADE MODERATE AMOUNTS OF STRESS CAN PROVOKE MODEST OVERCOMPENSATION INTERMITTENT EXPOSURES CAN PROMPT ADAPTATION

OPTIMAL STRESSORS DEPRIVING ONESELF OF HALF A NIGHT’S SLEEP ONCE A WEEK PREFERABLY THE SECOND HALF OF THE NIGHT (FOR EXAMPLE, 3 – 7 AM)

CAN PRODUCE A RAPID, EVEN IF SHORT – LIVED, RESTABILIZATION OF MOOD AND RECOVERY FROM DEPRESSION THE “STRESS” OF INTERRUPTING NORMAL SLEEP PATTERNS MAY “RESYNCHRONIZE DISTURBED CIRCADIAN RHYTHMS” (LEIBENLUFT & WEHR 1992)

INTERMITTENT FASTING FOR EXAMPLE, A 36 – HOUR WATER FAST ONCE A WEEK FROM AFTER DINNER, SAY, ON MONDAY TO BEFORE BREAKFAST ON WEDNESDAY

CAN SO SIGNIFICANTLY REDUCE THE TOTAL BODY BURDEN THAT MENTAL CLARITY AND FOCUS CAN BE IMPROVED DRAMATICALLY AND A SENSE OF OVERALL WELL – BEING RESTORED IT IS ALSO ASSOCIATED WITH HIGHER LEVELS OF BRAIN – DERIVED NEUROTROPHIC FACTOR (BDNF) A PROTEIN THAT PREVENTS STRESSED NEURONS FROM DYING

(MATTSON 2015)

OPTIMAL STRESSORS

(CONTINUED)

MODERATE AEROBIC EXERCISE A TEAM OF RESEARCHERS AT DUKE UNIVERSITY MEDICAL CENTER DEMONSTRATED THAT AEROBIC EXERCISE IS AT LEAST AS EFFECTIVE AS MEDICATION IN TREATING MAJOR DEPRESSION IT ALSO IMPROVES COGNITIVE ABILITY, PARTICULARLY IN THE FRONTAL AND PREFRONTAL REGIONS OF THE BRAIN THEY DISCOVERED THAT IF YOU DO 40 MINUTES OF AEROBIC EXERCISE DURING THE DAY, THEN YOU WILL NEED 40 MINUTES LESS OF SLEEP THAT NEXT NIGHT (BLUMENTHAL et al. 1999)

EVERY – OTHER – DAY WORKOUTS ARE PARTICULARLY EFFECTIVE WORKOUTS CREATE MICROTEARS THAT THE BODY CAN THEN REPAIR ON THOSE DAYS WHEN THE BODY IS AT REST

MOST EFFECTIVE IS HIGH – INTENSITY INTERVAL TRAINING AN EXERCISE STRATEGY THAT ALTERNATES PERIODS OF SHORT INTENSE ANAEROBIC EXERCISE WITH LESS INTENSE RECOVERY PERIODS THE CYCLES OF FIRST CHALLENGE (WITH ANAEROBIC ACTIVITY) AND THEN SUPPORT (WITH AEROBIC ACTIVITY) ARE THOUGHT TO FINE – TUNE THE MindBodyMatrix AND OPTIMIZE ITS FUNCTIONALITY

OPTIMAL STRESSORS

(CONTINUED)

“PIN FIRING” PARTIALLY HEALED TENDONS IN INJURED RACEHORSES TO ACCELERATE HEALING INSERTION OF SMALL, RED – HOT PROBES INTO, SAY, AN 80% HEALED TENDON IN ORDER TO CAUSE AGGRAVATIONS THAT WILL THEN TRIGGER THE HORSE’S SELF – HEALING MECHANISMS IN OTHER WORDS, BY SUPERIMPOSING AN ACUTE INJURY ON TOP OF A CHRONIC ONE, PIN FIRING CONVERTS A CHRONIC INFLAMMATORY PROCESS INTO AN ACUTE ONE SINCE 2006 IT HAS BEEN APPROVED FOR VETERINARIANS AS AN ACCEPTABLE FORM OF THERAPY IN CASES REFRACTORY TO CONVENTIONAL TREATMENT

ACUPUNCTURE A KEY COMPONENT OF TRADITIONAL CHINESE MEDICINE INSERTION OF THIN NEEDLES INTO SPECIFIC POINTS ON THE BODY IN ORDER TO RESTORE THE FLOW OF ENERGY AND RELIEVE PAIN BY SIMULATING AN INJURY WITHOUT ACTUALLY DAMAGING THE TISSUE, THE MILD STIMULUS IS THOUGHT TO TUNE UP THE REPAIR CHANNELS

FRAXEL LASER TREATMENTS TO STIMULATE REGENERATION OF FACIAL COLLAGEN

DERMABRASION INFLICT CONTROLLED DAMAGE TO PRODUCE YOUNGER, SMOOTHER, SOFTER, HEALTHIER SKIN

OPTIMAL STRESSORS

(CONTINUED)

HOMEOPATHIC REMEDIES TO ACTIVATE THE BODY’S ABILITY TO HEAL ITSELF

LIKE CURES LIKE – THE LAW OF SIMILARS (HAHNEMANN 2008) TREATMENT OF A RATTLESNAKE BITE WITH A DILUTED SOLUTION OF SNAKE VENOM OR HIGH FEVERS AND THROBBING HEADACHES WITH A DILUTED SOLUTION OF BELLADONNA ALLOPATHY – THE MAINSTREAM METHOD OF TREATING DISEASES WITH SUBSTANCES THAT PRODUCE EFFECTS OPPOSITE TO THOSE PRODUCED BY THE DISEASE ANTIPYRETICS TO TREAT FEVERS / ANTI – INFLAMMATORIES TO REDUCE INFLAMMATION ANTITUSSIVES TO SUPPRESS COUGHS / ANTIEMETICS FOR NAUSEA AND VOMITING HOMEOPATHY – AN ALTERNATIVE METHOD OF TREATING DISEASES WITH SUBSTANCES THAT PRODUCE EFFECTS SIMILAR TO THOSE PRODUCED BY THE DISEASE BUT IN DOSES SO SMALL THAT THE BODY’S NATURAL HEALING PROCESSES WILL BE ACTIVATED THE KEY TO THE EFFECTIVENESS OF A “DYNAMIZED” HOMEOPATHIC REMEDY – THE ADMINISTRATION OF MINUTE DOSES OF A POTENTIZED SUBSTANCE, WHICH MEANS THAT THE SUBSTANCE HAS BEEN SERIALLY DILUTED AND SUCCUSSED IN ORDER TO RELEASE ITS FULL ENERGETIC POTENTIAL THE SOLUTION CONTAINS A MEMORY (ENERGETIC SIGNATURE) OF THE SUBSTANCE, WHICH THEN PROMPTS THE BODY TO MOBILIZE ITS DEFENSES / RESOURCES

OPTIMAL STRESSORS

(CONTINUED)

VACCINATION / IMMUNOTHERAPY ADMINISTERING EITHER A SINGLE RELATIVELY SMALL DOSE OF ALLERGEN OR A SERIES OF VERY SMALL DOSES OVER A PERIOD OF TIME WILL STIMULATE THE BODY’S IMMUNE SYSTEM AND PROMOTE THE BODY’S RESISTANCE TO SUBSEQUENT EXPOSURES THE VARIOUS FORMS OF IMMUNOTHERAPY (INCLUDING VACCINATIONS) PREPARE THE BODY FOR FUTURE CHALLENGES BY INDUCING TOLERANCE (aka ACQUIRED TOLERANCE OR ADAPTIVE IMMUNITY) AND INCLUDE SUCH IMMUNE – STRENGTHENING TECHNIQUES AS PROVOCATION – NEUTRALIZATION TESTING ENZYME POTENTIATED DESENSITIZATION (EPD) LOW – DOSE ANTIGEN THERAPY (LDA) NAMBUDRIPAD’S ALLERGY ELIMINATION TECHNIQUE (NAET)

THE THEORY BEHIND SUCH TREATMENTS IS THAT SINGLE OR INTERMITTENT EXPOSURES TO DOSES THAT DO NOT OVERWHELM THE BODY WILL INSTEAD PROMPT THE BODY TO ADAPT, THEREBY PROMOTING RESISTANCE TO SUBSEQUENT EXPOSURES

CLASSICAL (PAVLOVIAN) CONDITIONING IS A LEARNING PROCESS WHEREBY A NEUTRAL STIMULUS (FOR EXAMPLE, THE SOUND OF A BELL) WILL OVER TIME BECOME ASSOCIATED WITH A POTENT STIMULUS (FOR EXAMPLE, THE SMELL OF MEAT) THAT TRIGGERS AN INNATE REFLEX (FOR EXAMPLE, SALIVATION) THIS ASSOCIATIVE LINK IS ACHIEVED BY WAY OF REPEATED PAIRINGS OF THE NEUTRAL STIMULUS WITH THE POTENT STIMULUS, SUCH THAT THE PREVIOUSLY NEUTRAL STIMULUS WILL ITSELF EVENTUALLY ELICIT THE INNATE REFLEX OR RESPONDENT BEHAVIOR

SYSTEMATIC DESENSITIZATION ALSO KNOWN AS GRADUATED EXPOSURE THERAPY

IS A FORM OF COUNTERCONDITIONING DEVELOPED BY JOSEPH WOLPE, IT IS A BEHAVIORAL TECHNIQUE BASED ON THE PRINCIPLE OF CLASSICAL CONDITIONING AND USED TO TREAT FEARS, PHOBIAS, AND OTHER ANXIETY DISORDERS THE PATIENT IS TAUGHT TO ENGAGE IN SOME TYPE OF RELAXATION EXERCISE (FOR EXAMPLE, BREATH WORK) AND IS GRADUALLY EXPOSED (IN EVER – INCREASING DOSES) TO AN ANXIETY – PROVOKING STIMULUS (FOR EXAMPLE, FEAR OF HEIGHTS) THE PATIENT WORKS HER WAY UP THE ANXIETY HIERARCHY, FROM THE LEAST STRESSFUL TO THE MOST STRESSFUL

WHILE PRACTICING HER RELAXATION TECHNIQUE THE GOAL OF THIS OPTIMALLY STRESSFUL PROCESS IS TO BECOME GRADUALLY DESENSITIZED TO THE TRIGGER THAT IS CAUSING THE DISTRESS

Module 4

THE SANDPILE MODEL AND

THE PARADOXICAL IMPACT OF STRESS

THE NOTED 16TH CENTURY SWISS PHYSICIAN PARACELSUS (2004) IS CREDITED WITH HAVING WRITTEN THAT

THE DIFFERENCE BETWEEN A POISON AND A MEDICATION IS THE DOSAGE THEREOF ONE MIGHT ADD, HOWEVER, THAT IT IS THE SYSTEM’S CAPACITY TO PROCESS, INTEGRATE, AND ULTIMATELY ADAPT TO THE IMPACT OF THE STRESSOR THAT WILL ULTIMATELY MAKE THE DIFFERENCE SO A POISON IS NOT ALWAYS TOXIC, AND NOR IS A MEDICINE ALWAYS THERAPEUTIC FOR EXAMPLE, IF A DEPRESSED PATIENT IS RESPONDING TO 20 MG OF FLUOXETINE, BUT ONLY SUBOPTIMALLY, PERHAPS 10 MG WILL BE THE “MORE” OPTIMAL DOSE AND NOT EVER – HIGHER DOSES OF THIS SELECTIVE SEROTONIN REUPTAKE INHIBITOR AND WHEREAS MILD TO MODERATE EXERCISE WILL USUALLY ENERGIZE THE BODY, EXCESSIVE OR PROLONGED EXERCISE MAY ULTIMATELY DEPLETE THE BODY OF ITS ADAPTATION RESERVES

THEREFORE STRESSFUL INPUT IS INHERENTLY NEITHER BAD (POISON) NOR GOOD (MEDICATION) RATHER, THE DOSAGE OF THE STRESSOR, THE UNDERLYING RESILIENCE OF THE SYSTEM, AND THE INTERFACE BETWEEN STRESSOR AND SYSTEM WILL DETERMINE IF THE PATIENT DEFENDS AND DEVOLVES TO EVER – GREATER DISORGANIZATION OR ADAPTS AND EVOLVES BY WAY OF A SERIES OF HEALING CYCLES

TO EVER MORE COMPLEX LEVELS OF ORGANIZATION AND DYNAMIC BALANCE

IN OTHER WORDS

IF THE INTERFACE BETWEEN STRESSOR AND SYSTEM IS SUCH THAT THE STRESSOR IS ABLE TO PROVOKE RECOVERY WITHIN THE SYSTEM, THEN WHAT WOULD HAVE BEEN THOUGHT TO BE A POISON WILL BECOME MEDICATION WHAT WOULD HAVE CONSTITUTED TOXIC INPUT WILL BECOME THERAPEUTIC INPUT WHAT WOULD HAVE OVERWHELMED WILL BECOME TRANSFORMATIVE WHAT WOULD HAVE BEEN DEEMED TRAUMATIC STRESS WILL BECOME OPTIMAL STRESS

HISTORICALLY

THE TOXICOLOGICAL LITERATURE HAS EMBRACED A LINEAR “NO – THRESHOLD” DOSE – RESPONSE MODEL WHEREBY TOXINS ARE THOUGHT TO BE “TOXIC” AT WHATEVER THEIR DOSE BUT THE CONCEPT OF HORMESIS LONG MARGINALIZED IN THE TOXICOLOGICAL LITERATURE

IS NOW SLOWLY GAINING ACCEPTANCE THROUGH THE EXTRAORDINARY RESEARCH EFFORTS OF THE AVANT – GARDE TOXICOLOGIST EDWARD CALABRESE (2008) WHEREBY AN AGENT (A STRESSOR) GENERALLY THOUGHT TO BE TOXIC OR INHIBITORY AT A HIGH DOSE WILL OFTEN BE THERAPEUTIC OR STIMULATORY AT A LOWER DOSE CALABRESE HYPOTHESIZES THAT THIS EXCITATORY RESPONSE IS A MANIFESTATION OF THE SYSTEM’S ADAPTIVE RESPONSE TO LOW – LEVEL STRESS

MORE SPECIFICALLY

LOW – LEVEL STRESS IS THOUGHT TO PROVOKE A SYSTEM’S “MODEST OVERCOMPENSATION” IN THE FACE OF THREATENED DISRUPTION TO ITS HOMEOSTASIS CALABRESE HYPOTHESIZES THAT HORMESIS IS AN ALMOST UNIVERSAL BIOLOGICAL PHENOMENON IN SUM IN CONTRADISTINCTION TO A LINEAR NO – THRESHOLD DOSE – RESPONSE CURVE

A HORMETIC DOSE – RESPONSE CURVE WILL BE “BIPHASIC” THAT IS, WHEREAS HIGH DOSES WILL INHIBIT AND THEREFORE BE HARMFUL

LOW DOSES WILL STIMULATE AND THEREFORE BE BENEFICIAL HIGH – DOSE STRESS “BAD” / LOW – DOSE STRESS “GOOD” HIGH – DOSE STRESS “TOXIC” / LOW – DOSE STRESS “THERAPEUTIC”

HIGH – DOSE STRESS “TRAUMATIC” / LOW – DOSE STRESS “OPTIMAL”

SHIFTING NOW FROM THE REALM OF THE ANIMATE TO THE REALM OF THE INANIMATE

THE SANDPILE MODEL AND THE PARADOXICAL IMPACT OF STRESS LONG INTRIGUING TO CHAOS THEORISTS HAS BEEN THE SANDPILE MODEL (BAK 1996) WHICH IS A PRIME EXAMPLE OF AN OPEN, COMPLEX ADAPTIVE, SELF – ORGANIZING (CHAOTIC) SYSTEM

THIS SIMULATION MODEL IS USED TO DEMONSTRATE THE CUMULATIVE IMPACT OVER TIME

OF ENVIRONMENTAL STRESSORS ON OPEN (CHAOTIC) SYSTEMS EVOLUTION OF THE SANDPILE IS GOVERNED BY SOME COMPLEX MATHEMATICAL FORMULAS AND IS WELL KNOWN IN MANY SCIENTIFIC CIRCLES …

… BUT THE MODEL IS RARELY APPLIED TO LIVING SYSTEMS AND IS NEVER USED TO DEMONSTRATE EITHER THE REGULATORY CAPACITY OF THE LIVING SYSTEM OR THE PARADOXICAL IMPACT OF STRESS ON IT

I BELIEVE, HOWEVER, THAT THE SANDPILE MODEL PROVIDES AN ELEGANT VISUAL METAPHOR FOR HOW THE LIVING SYSTEM IS CONTINUOUSLY REFASHIONING ITSELF AT EVER – HIGHER LEVELS OF COMPLEXITY AND INTEGRATION

NOT JUST “IN SPITE OF” STRESSFUL INPUT FROM THE OUTSIDE BUT “BY WAY OF” THAT INPUT

THE SANDPILE MODEL AND THE PARADOXICAL IMPACT OF STRESS AMAZINGLY ENOUGH, THE GRAINS OF SAND BEING STEADILY ADDED TO THE GRADUALLY EVOLVING SANDPILE ARE THE OCCASION FOR BOTH ITS DISRUPTION AND ITS REPAIR NOT ONLY DO THE GRAINS OF SAND BEING ADDED PRECIPITATE PARTIAL COLLAPSE OF THE SANDPILE BUT ALSO THEY BECOME THE MEANS BY WHICH THE SANDPILE WILL BE ABLE TO BUILD ITSELF BACK UP – EACH TIME AT A NEW LEVEL OF HOMEOSTASIS THE SYSTEM WILL THEREFORE HAVE BEEN ABLE NOT ONLY TO MANAGE THE IMPACT OF THE STRESSFUL INPUT BUT ALSO TO BENEFIT FROM THAT IMPACT

THE SANDPILE MODEL AND THE PARADOXICAL IMPACT OF STRESS AS THE SANDPILE EVOLVES AN UNDERLYING PATTERN WILL BEGIN TO EMERGE CHARACTERIZED BY RECURSIVE CYCLES OF FIRST DESTABILIZATION A DEFENSIVE REACTION TO THE STRESSFUL IMPACT OF THE GRAINS OF SAND

AND THEN RESTABILIZATION AT EVER – HIGHER LEVELS OF COMPLEX ORGANIZATION AND DYNAMIC BALANCE AN ADAPTIVE RESPONSE TO THAT IMPACT

I HAVE CREATED A GRAPH THAT DEPICTS THREE STAGES IN THE EVOLUTION OF A SANDPILE OVER TIME

STAGE 1 (MINIMAL LOAD) IN RESPONSE TO “MINIMALLY STRESSFUL” INPUT

ONGOING HOMEOSTATIC ADJUSTMENTS STAGE 2 (OPTIMAL LOAD) IN RESPONSE TO “OPTIMALLY STRESSFUL” INPUT

ITERATIVE CYCLES OF DISRUPTION (MINOR AVALANCHE) FOLLOWED BY REPAIR (MODEST OVERCOMPENSATION) STAGE 3 (OVERLOAD) ONCE THE SYSTEM’S ADAPTATION (NUTRIENT AND ENERGETIC) RESERVES HAVE BECOME DEPLETED, A TIPPING POINT WILL BE REACHED AND AS A REACTION TO ANY ADDITIONAL, NOW “TRAUMATICALLY STRESSFUL” INPUT

THERE WILL BE TOTAL COLLAPSE OF THE SYSTEM (MAJOR AVALANCHE) (STARK 2015)

THE HEALTH OF A SYSTEM IS THEREFORE A STORY ABOUT ITS CAPACITY TO ADAPT THAT IS, ITS ABILITY TO SELF – REGULATE

AND TO RESTORE ITS HOMEOSTATIC BALANCE IN THE FACE OF CHALLENGE

CONTINUOUS ADJUSTMENT TO INSTABILITY IMPLICIT IN THIS CONCEPTUALIZATION OF SELF – REGULATION IS THE COMPELLING IDEA THAT A LIVING SYSTEM WILL BE ABLE TO PRESERVE ITS STABILITY ONLY BY WAY OF CONTINUOUS ADJUSTMENT TO INSTABILITY “THE ABILITY TO SURVIVE CHANGE BY CHANGING”

(MEADOWS 1997)

IN 1965, TWO OBSTETRICIANS MADE AN INTRIGUING DISCOVERY ABOUT THE PARADOXICAL RELATIONSHIP BETWEEN REGULARITY OF FETAL HEART RATE AND FETAL MORTALITY THEY FOUND THAT THE MORE METRONOME – LIKE THE HEARTBEAT, THE LESS LIKELY THE FETUS WOULD BE TO SURVIVE WHEREAS THE GREATER THE HEART RATE VARIABILITY, THAT IS, THE MORE VARIABLE THE HEART’S BEAT – TO – BEAT INTERVALS,

THE MORE LIKELY THE FETUS WOULD BE TO THRIVE

(HON 1965)

RESILIENCE SPEAKS TO THIS ABILITY CONTINUOUSLY TO ADJUST TO ONGOING ENVIRONMENTAL PERTURBATION AND ADAPTIVELY TO REORGANIZE AT EVER – NEWER HOMEOSTATIC SET POINTS

IN SUM

HEALTH SPEAKS TO THE CAPACITY CONTINUOUSLY TO ADJUST TO ONGOING ENVIRONMENTAL PERTURBATION THAT IS, TO THE STRESS OF THOSE GRAINS OF SAND

AND ADAPTIVELY TO RECONSTITUTE AT EVER – NEWER HOMEOSTATIC SET POINTS

Module 5

THE WEB OF LIFE AND

RESILIENCE

WHETHER DESCRIBED AS

THE EXTRACELLULAR MATRIX

(REA & PATEL 2010)

THE GROUND REGULATION SYSTEM (PISCHINGER & HEINE 2007)

THE CONNECTIVE TISSUE MATRIX THE WEB OF LIFE THE LIVING MATRIX THE DIVINE MATRIX

(CAPRA 1997) (OSCHMAN 2000) (BRADEN 2008)

OR THE MindBodyMatrix

(STARK 2008)

THE LIVING SYSTEM IS

A NETWORK OF RELATIONSHIPS AN INTRICATE WEB OF INTERDEPENDENT LIVING TISSUE THAT EXTENDS FROM THE SURFACE OF THE BODY TO ITS INNERMOST RECESSES ULTIMATELY PENETRATING EVERY SINGLE CELL IN THE BODY

THE GROUND REGULATION SYSTEM ALBERT SZENT – GYORGYI, HARTMUT HEINE, ALFRED PISCHINGER, ROBERT BECKER, FRITZ – ALBERT POPP, AND JAMES OSCHMAN

ARE ALL RESEARCH SCIENTISTS DEDICATED TO UNDERSTANDING ON BOTH MOLECULAR AND SUBMOLECULAR LEVELS

THE COMPLEX WORKINGS OF THE HIGH – SPEED, BODY – WIDE INFORMATION AND ENERGY DISSEMINATION SYSTEM RESPONSIBLE FOR THE MAINTENANCE OF HOMEOSTASIS A VAST NETWORK OF INTERLOCKING COMPONENTS, REGULATORY PROCESSES, AND NEGATIVE / POSITIVE FEEDBACK LOOPS THROUGH WHICH THE FLOW OF LIFE TAKES PLACE

THIS LIVING MATRIX CONSTITUTES A BODY CONSCIOUSNESS WORKING IN TANDEM WITH THE BRAIN CONSCIOUSNESS OF THE NERVOUS SYSTEM

MORE SPECIFICALLY

THIS WEB OF LIFE IS A CONTINUOUS MESHWORK OF CONNECTIVE TISSUE FIBERS MADE UP OF STRUCTURAL GLYCOPROTEINS (COLLAGEN AND ELASTIN) AND CROSS – LINKING GLYCOPROTEINS (FIBRONECTIN AND LAMININ)

DISPERSED THROUGHOUT AN AMORPHOUS GROUND SUBSTANCE A COLLOIDAL GEL CONSISTING PRIMARILY OF LARGE SUGAR – PROTEIN (PG / GAG) MACROMOLECULES, EACH CONTAINING A (POSITIVELY CHARGED) CORE PROTEIN BACKBONE TO WHICH (NEGATIVELY CHARGED) HIGHLY POLYMERIZED GLYCAN SIDE CHAINS ARE ATTACHED LIKE THE BRISTLES ON A BRUSH

THESE SIDE CHAINS ARE TIGHTLY BOUND TO POLARIZED WATER MOLECULES

IN THE LANGUAGE OF SOLID – STATE PHYSICS

THIS GROUND REGULATION SYSTEM IS A LIQUID CRYSTAL MORE SPECIFICALLY

BECAUSE THE LIVING MATRIX IS A HIGHLY ORDERED ARRAY OF MOLECULES CLOSELY PACKED AND TIGHTLY ORGANIZED IN A CRYSTAL – LIKE LATTICE STRUCTURE,

IT HAS THE SEMICONDUCTING PROPERTIES OF A CRYSTAL AND, AS SUCH, ALLOWS FOR THE NEAR – INSTANTANEOUS FLOW OF REGULATORY INFORMATION AND VIBRATORY ENERGY THROUGHOUT THE ENTIRE FABRIC OF THE BODY

THIS CRYSTALLINITY ENABLES THE LIVING MATRIX WITH ITS STRUCTURAL AND CROSS – LINKING GLYCOPROTEINS, ITS LONG – CHAIN, SUGAR – PROTEIN COMPLEXES, AND ITS TIGHTLY BOUND LAYERS OF POLARIZED WATER

TO CONDUCT BIOPHOTONS (UNITS OF INFORMATION AND ENERGY)

AT ABOUT THE SPEED OF LIGHT TRANSMITTING BOTH

INFORMATION (LIKE THE WIRE TO A LAND – LINE TELEPHONE)

AND ENERGY (LIKE THE WIRE TO A TOASTER)

AN ASTOUNDINGLY COMPLEX GLOBAL COMMUNICATION SYSTEM

THE DIRECT CURRENTS GENERATED IN THE MATRIX ARE NOT A RESULT OF THE RELATIVELY SLOW MOVEMENT OF CUMBERSOME IONS (SODIUM AND POTASSIUM) ACROSS THE MEMBRANE OF A NERVE CELL THAT BECOMES FIRST DEPOLARIZED AND THEN REPOLARIZED AS AN ELECTRIC IMPULSE IS CONDUCTED DOWN THE LENGTH OF THE AXON AT SPEEDS RANGING FROM 1.5 TO 400 FEET PER SECOND RATHER, THE SPEED OF PROPAGATION OF A DIRECT CURRENT THROUGH THE LIVING MATRIX IS CLOSER TO THE SPEED OF LIGHT – 186,000 MILES PER SECOND “THE DIRECT CURRENTS ARE NOT DUE BUT INSTEAD DEPEND ON CHARACTERISTIC OF

MAKING UP THE BODY FIELD TO CHARGED IONS A MODE OF SEMICONDUCTION SOLID – STATE SYSTEMS.” (BECKER 1998)

WHETHER THE UNITS OF INFORMATION AND ENERGY ARE DESCRIBED AS

ELECTRONS, BIOPHOTONS, LIFE PARTICLES, EXCITATIONS OF A QUANTUM FIELD, OR ENERGY QUANTA WHETHER THE FLOW IS OF

DISCONTINUOUS PARTICLES OR CONTINUOUS WAVES THE WAVE – PARTICLE DUALITY OF QUANTUM PHYSICS WHETHER THE TRANSPORT SYSTEM INVOLVES

COLLAGEN FIBRILS OUTSIDE THE CELLS, MICROTUBULES INSIDE THE CELLS, OR SUGAR – PROTEIN MACROMOLECULES IN THE INTERSTITIAL GROUND SUBSTANCE WHETHER THE PROPAGATION IS BY WAY OF

LAYERS OF ELECTRICALLY CHARGED WATER, THE PERINEURAL DC SYSTEM, ACUPUNCTURE MERIDIANS, OR ENERGY CHANNELS AND WHETHER THE SPEED OF TRANSMISSION IS

THE SPEED OF SEMICONDUCTIVITY, THE SPEED OF LIGHT, OR SIMPLY INSTANTANEOUS …

THE TEAM OF INTERDISCIPLINARY RESEARCH SCIENTISTS WHO HAVE DEVOTED THEIR CAREERS TO THE STUDY OF THESE ESOTERIC CONCEPTS WHATEVER THEIR SPECIFIC FIELD OF STUDY AND WHATEVER THEIR LEXICON

SHARE A COMMON DREAM NAMELY

TO UNRAVEL THE SECRET OF LIFE BY STUDYING THE INNER WORKINGS ON THE MOST ELEMENTAL LEVEL

OF THE LIVING SYSTEM

THE TAKE – HOME HERE

THE HALLMARK OF A HEALTHY SYSTEM IS ITS CAPACITY TO COPE WITH STRESS WHICH WILL IN TURN BE A STORY ABOUT ITS ABILITY TO PROCESS AND INTEGRATE THE IMPACT OF ENVIRONMENTAL PERTURBATION WHICH WILL IN TURN BE A REFLECTION OF THE UNDERLYING ORDEREDNESS OF THE SYSTEM AND THE RESULTANT EASE WITH WHICH INFORMATION AND ENERGY CAN BE TRANSMITTED THROUGHOUT ITS EXPANSE

“LACK OF ORDER” MANIFESTING AS

PSYCHIATRIC / MEDICAL “DIS – ORDER” AND

“DISRUPTED EASE OF FLOW” MANIFESTING AS

PSYCHIATRIC / MEDICAL “DIS – EASE”

TO REVERSE THE DYSFUNCTION CAUSED BY THE CUMULATIVE IMPACT OF ENVIRONMENTAL TOXICITIES AND DEFICIENCIES

THE ORDEREDNESS AND FLUIDITY OF THE SYSTEM’S INFRASTRUCTURE MUST BE RESTORED WITH TARGETED THERAPIES THAT “LIGHTEN THE LOAD” TO CORRECT FOR TOXICITIES AND “REPLENISH THE RESERVES” TO CORRECT FOR DEFICIENCIES ALL WITH AN EYE TO “FACILITATING THE FLOW” OF INFORMATION AND ENERGY THROUGHOUT THE SYSTEM THEREBY REVITALIZING ITS RESILIENCE AND CAPACITY TO COPE WITH THE STRESS OF LIFE (STARK 2012, 2014, 2015)

AT THE END OF THE DAY

THE GOAL OF ANY HOLISTIC TREATMENT BE ITS FOCUS PSYCHOLOGICAL OR PHYSICAL

MUST THEREFORE BE TO RESTORE THE INTRINSIC ORDEREDNESS AND FLUIDITY OF THE MindBodyMatrix SO THAT STRESSFUL CHALLENGES CAN BE MORE EFFECTIVELY MASTERED

Module 6

A HOLISTIC CONCEPTUAL FRAMEWORK AND

THE IMPACT OF PSYCHOLOGICAL AND PHYSIOLOGICAL STRESSORS

MY HOPE IS THAT WHAT FOLLOWS WILL BE RELEVANT IN THE WORK THAT YOU DO WITH YOUR PATIENTS … WHATEVER YOUR ORIENTATION WHATEVER THE PATIENT’S DIAGNOSIS WHATEVER HER UNDERLYING PSYCHODYNAMICS HOWEVER SHORT OR LONG THE TREATMENT AT WHATEVER MOMENT IN TIME WHETHER AT THE BEGINNING, IN THE MIDDLE, OR AT THE END OF A TREATMENT

“ONE OF SCIENCE’S GREATEST CHALLENGES IS TO DISCOVER CERTAIN PRINCIPLES THAT WILL EXPLAIN, INTEGRATE, AND PREDICT LARGE NUMBERS OF SEEMINGLY UNRELATED PHENOMENA.” (SCHWARTZ 1999)

DRAWING UPON CONCEPTS FROM FIELDS AS DIVERSE AS SYSTEMS THEORY, CHAOS THEORY, QUANTUM MECHANICS, SOLID – STATE PHYSICS, TOXICOLOGY, AND PSYCHOANALYSIS

I WILL BE OFFERING WHAT I HOPE WILL PROVE TO BE A CLINICALLY USEFUL CONCEPTUAL FRAMEWORK FOR UNDERSTANDING THE PROCESS OF HEALING BE IT OF CHRONIC PSYCHIATRIC OR MEDICAL CONDITIONS

PREVIEW THE THERAPEUTIC USE OF OPTIMAL STRESS TO PROVOKE RECOVERY THE TASK OF THE CHILD (GROWING UP) THE TASK OF THE PATIENT (GETTING BETTER) TRANSFORMATION OF DYSFUNCTIONAL DEFENSE INTO MORE FUNCTIONAL ADAPTATION WHERE ID WAS, THERE SHALL EGO BE WHERE DEFENSE WAS, THERE SHALL ADAPTATION BE

AN ONGOING PROCESS INVOLVING HEALING CYCLES OF DISRUPTION AND REPAIR THE THERAPIST WILL PRECIPITATE DISRUPTION IN ORDER TO TRIGGER REPAIR BY WAY OF OPTIMALLY STRESSFUL THERAPEUTIC INTERVENTIONS THAT ALTERNATELY CHALLENGE AND THEN SUPPORT THE DEFENSE

PREVIEW ITERATIVE CYCLES OF DESTABILIZATION IN REACTION TO CHALLENGE

AND IN RESPONSE TO SUPPORT AND BY TAPPING INTO THE PATIENT’S UNDERLYING RESILIENCE

RESTABILIZATION AT EVER – HIGHER LEVELS OF FUNCTIONALITY AND ADAPTIVE CAPACITY IN ESSENCE BY CHALLENGING DEFENSES TO WHICH THE PATIENT HAS LONG CLUNG, PSYCHODYNAMIC PSYCHOTHERAPY OFFERS THE PATIENT A BELATED OPPORTUNITY TO PROCESS, INTEGRATE, AND ADAPT TO PREVIOUSLY UNMASTERED AND THEREFORE DEFENDED AGAINST

EARLY – ON EXPERIENCE

PREVIEW THREE MODES OF THERAPEUTIC ACTION THREE APPROACHES TO TRANSFORMING DEFENSE INTO ADAPTATION THREE OPTIMAL STRESSORS THAT FACILITATE THIS ACTION

TRANSFORMATION OF RESISTANCE INTO AWARENESS AND ACTUALIZATION OF POTENTIAL BY WORKING THROUGH THE STRESS OF COGNITIVE DISSONANCE (THE EXPERIENCE OF GAIN – BECOME – PAIN)

TRANSFORMATION OF RELENTLESSNESS INTO ACCEPTANCE BY WORKING THROUGH THE STRESS OF AFFECTIVE DISILLUSIONMENT (THE EXPERIENCE OF GOOD – BECOME – BAD)

TRANSFORMATION OF RE – ENACTMENT INTO ACCOUNTABILITY BY WORKING THROUGH THE STRESS OF RELATIONAL DETOXIFICATION (THE EXPERIENCE OF BAD – BECOME – GOOD)

AGAIN

STRESSFUL STUFF HAPPENS BUT IT WILL BE HOW WELL WE ARE ULTIMATELY ABLE TO MANAGE THE IMPACT OF STRESS IN OUR LIVES THAT WILL EITHER DERAIL OUR DEVELOPMENT WHEN ALL WE KNOW HOW TO DO IS TO REACT DEFENSIVELY

OR TRIGGER OUR GROWTH ONCE WE HAVE BECOME ABLE TO RESPOND ADAPTIVELY TO THE MYRIAD OF DISAPPOINTMENTS, FRUSTRATIONS, AND LOSSES WITH WHICH LIFE WILL INEVITABLY CONFRONT US

IN MY OWN WRITINGS

I HAVE FOUND IT CLINICALLY USEFUL TO CONCEIVE OF PSYCHOLOGICAL STRESSORS ESPECIALLY RELEVANT IN THE EARLY – ON PARENT – CHILD RELATIONSHIP

AS INVOLVING BOTH “TOO MUCH THAT WAS BAD” AND “NOT ENOUGH THAT WAS GOOD” MORE SPECIFICALLY

THE “PRESENCE OF BAD” PARENTAL ERRORS OF COMMISSION TRAUMA AND ABUSE / TOXICITIES

AND THE “ABSENCE OF GOOD” PARENTAL ERRORS OF OMISSION DEPRIVATION AND NEGLECT / DEFICIENCIES

SO TOO PHYSIOLOGICAL STRESSORS INVOLVE BOTH TOXICITIES AND DEFICIENCIES

WHETHER THE PRIMARY TARGET IS MIND OR BODY AND THE CLINICAL MANIFESTATION THEREFORE PSYCHIATRIC OR MEDICAL

THE CRITICAL ISSUE WILL BE THE ABILITY OF THE MindBodyMatrix TO HANDLE STRESS THROUGH ADAPTATION IN THE PSYCHOLOGICAL REALM

AN EXAMPLE OF ADAPTATION – HANDLING THE STRESS OF THE LOSS OF A LOVED ONE BY CONFRONTING – AND GRIEVING – THE PAIN OF ONE’S HEARTBREAK AND ULTIMATELY EVOLVING FROM ANGER, UPSET, AND FEELINGS OF HELPLESSNESS TO SERENE ACCEPTANCE IN THE PHYSIOLOGICAL REALM

AN EXAMPLE OF ADAPTATION – HANDLING THE STRESS OF BLOCKED CORONARY ARTERIES BY DEVELOPING NEW (COLLATERAL) ONES TO SUPPLY THE HEART WITH THE NUTRIENTS AND OXYGEN IT NEEDS, THEREBY AVERTING A POTENTIAL HEART ATTACK

IN THE PSYCHOLOGICAL REALM

ANOTHER EXAMPLE OF DEFENSE WHEN THE IMPACT ON A CHILD OF HER PARENT’S ABUSIVENESS IS SIMPLY TOO MUCH FOR THE CHILD TO PROCESS, INTEGRATE, AND ADAPT TO THE CHILD MAY FIND HERSELF DEFENSIVELY REACTING BY DISSOCIATING OVER TIME, DISSOCIATION MAY EMERGE AS HER CHARACTERISTIC DEFENSIVE STANCE IN LIFE WHENEVER SHE FEELS THREATENED

IN THE PSYCHOLOGICAL REALM

ANOTHER EXAMPLE OF ADAPTATION BUT WHEN THE IMPACT ON A CHILD OF HER PARENT’S ABUSIVENESS IS ULTIMATELY ABLE TO BE MASTERED THAT IS,

PROCESSED AND INTEGRATED

THE CHILD MAY ADAPTIVELY RESPOND BY BECOMING AN ADVOCATE FOR THE RIGHTS OF HER LITTLE SISTER AND OF OTHERS WHOM SHE SENSES MIGHT BE AT RISK

IN THE PHYSIOLOGICAL REALM

HYPOTHYROIDISM IN ITS INFINITE WISDOM, THE BODY WILL KNOW TO ADAPT BY REDISTRIBUTING ITS BLOOD FLOW FROM LESS ESSENTIAL TO MORE ESSENTIAL ORGAN SYSTEMS THUS THE THIN FRAGILE SKIN, DRY BRITTLE HAIR, AND TELLTALE LOSS OF THE OUTER THIRD OF THE EYEBROWS SO CHARACTERISTIC OF HYPOTHYROIDISM

ACIDIC INTERNAL ENVIRONMENT IN ITS INFINITE WISDOM, THE BODY WILL KNOW TO ADAPT BY LEACHING CALCIUM FROM ITS BONES IN AN EFFORT TO BUFFER THE ACIDITY THE GOOD NEWS WILL BE THE RESTORATION OF ACID – BASE BALANCE THE BAD NEWS WILL BE THE POTENTIAL FOR DEMINERALIZATION OF THE BONES AND DEVELOPMENT OF OSTEOPENIA / OSTEOPOROSIS

Module 7

THE ULTIMATE GOAL OF PSYCHODYNAMIC PSYCHOTHERAPY AND

BELATED MASTERY

TO REPEAT

PSYCHODYNAMIC PSYCHOTHERAPY AFFORDS THE PATIENT AN OPPORTUNITY ALBEIT A BELATED ONE

TO MASTER EXPERIENCES THAT HAD ONCE BEEN OVERWHELMING AND THEREFORE DEFENDED AGAINST

BUT THAT CAN NOW WITH ENOUGH SUPPORT FROM THE THERAPIST AND BY TAPPING INTO THE PATIENT’S UNDERLYING RESILIENCE AND CAPACITY TO COPE WITH STRESS

BE PROCESSED AND INTEGRATED AND ULTIMATELY ADAPTED TO

THE OPPORTUNITY AFFORDED BY PSYCHODYNAMIC PSYCHOTHERAPY FOR BELATED MASTERY OF TRAUMATIC EXPERIENCES AND TRANSFORMATION OF DEFENSE INTO ADAPTATION SPEAKS TO THE POWER OF THE TRANSFERENCE WHEREBY

“THE HERE – AND – NOW IS IMBUED WITH THE PRIMAL SIGNIFICANCE OF THE THERE – AND – THEN”

(STARK 2015)

WHICH IS WHAT MAKES THE SUCCESSFUL WORKING THROUGH OF BOTH “POSITIVE TRANSFERENCE DISRUPTED” AND “NEGATIVE TRANSFERENCE” SO POWERFULLY HEALING

FROM DEFENSE TO ADAPTATION THE EVER – EVOLVING PSYCHODYNAMIC PROCESS AS ALREADY NOTED, DEFENSES AND ADAPTATIONS ARE SELF – PROTECTIVE MECHANISMS DESIGNED TO PRESERVE HOMEOSTATIC BALANCE BUT THE THERAPEUTIC GOAL IS TO TRANSFORM THE LESS – EVOLVED DEFENSES INTO MORE – EVOLVED ADAPTATIONS INITIALLY THE TRANSFORMATION CAN BE COMPARED TO A COMPUTER’S “SAVE AS” COMMAND, WHICH WILL CAUSE THE NEW DOCUMENT TO BE SAVED ALONGSIDE THE OLD DOCUMENT ULTIMATELY THE TRANSFORMATION CAN BE COMPARED TO A COMPUTER’S “SAVE” COMMAND, WHEREBY THE NEW DOCUMENT WILL BE SUPERIMPOSED UPON THE OLD DOCUMENT, THEREBY DELETING THE OLD DOCUMENT

THE DEVELOPMENTAL PROCESS AND THE THERAPEUTIC PROCESS WHERE ID WAS, THERE SHALL EGO BE WHERE DEFENSE WAS, THERE SHALL ADAPTATION BE

FROM ID TO EGO FROM ID DRIVE TO EGO STRUCTURE DRIVES GIVE RISE TO NEEDS AND STRUCTURES PERFORM FUNCTIONS THAT ENABLE CAPACITY

FROM ID NEED TO EGO CAPACITY FROM NEED TO CAPACITY FROM INFANTILE NEED TO ADULT CAPACITY FROM DEFENSIVE NEED TO ADAPTIVE CAPACITY FROM DEFENSIVE REACTION TO ADAPTIVE RESPONSE FROM DEFENSE TO ADAPTATION

INDEED

EGO PSYCHOLOGY IS FOUNDED ON THE PREMISE THAT THE EGO DEVELOPS OUT OF NECESSITY THAT IT EVOLVES AS AN ADAPTATION TO THE EXIGENCIES OF THE ID, THE IMPERATIVES OF THE SUPEREGO, AND THE DEMANDS OF EXTERNAL REALITY ALL OF WHICH ARE ENVIRONMENTAL STRESSORS (WHETHER INTERNAL OR EXTERNAL) THAT WILL EXACT THEIR TOLL UNLESS THEIR IMPACT CAN BE PROCESSED, INTEGRATED, AND ADAPTED TO

IN ESSENCE

ADAPTATION IS A STORY ABOUT MAKING A VIRTUE OUT OF NECESSITY J SUCH THAT

THE EGO WILL BECOME MORE “AWARE” AND ULTIMATELY MORE “ACTUALIZED” (MODEL 1) THE SELF MORE “ACCEPTING” (MODEL 2) AND THE SELF – IN – RELATION MORE “ACCOUNTABLE” (MODEL 3)

THE ULTIMATE GOAL OF PSYCHODYNAMIC PSYCHOTHERAPY IS TO FACILITATE THE PROCESSING AND INTEGRATING OF STRESSFUL EXPERIENCES IN BOTH THE THERE – AND – THEN AND THE HERE – AND – NOW

FROM DEFENSIVE REACTION

TO ADAPTIVE RESPONSE FROM DEFENSE

TO ADAPTATION FROM DYSFUNCTIONAL DEFENSE

TO MORE FUNCTIONAL ADAPTATION FROM DYSFUNCTIONAL ACTIONS, REACTIONS, AND INTERACTIONS

TO MORE FUNCTIONAL WAYS OF BEING AND DOING FROM DYSFUNCTION

TO FUNCTIONALITY FROM UNHEALTHY NEED

TO HEALTHY CAPACITY

FROM EXTERNALIZING BLAME

TO TAKING OWNERSHIP FROM WHINING AND COMPLAINING

TO BECOMING PROACTIVE FROM CURSING THE DARKNESS

TO LIGHTING A CANDLE FROM DISSOCIATING

TO BECOMING MORE PRESENT FROM FEELING VICTIMIZED

TO BECOMING EMPOWERED FROM BEING JAMMED UP

TO HARNESSING ONE’S ENERGIES SO THAT THEY CAN BE CHANNELED INTO THE PURSUIT OF ONE’S DREAMS FROM DENIAL

TO CONFRONTING HEAD – ON FROM BEING EVER CRITICAL

TO BECOMING MORE COMPASSIONATE

TO REPEAT

GROWING UP (THE TASK OF THE CHILD) AND GETTING BETTER (THE TASK OF THE PATIENT) ARE THEREFORE A STORY ABOUT

TRANSFORMING NEED INTO CAPACITY THE NEED FOR IMMEDIATE GRATIFICATION

INTO THE CAPACITY TO TOLERATE DELAY THE NEED FOR PERFECTION

INTO THE CAPACITY TO TOLERATE IMPERFECTION THE NEED FOR EXTERNAL REGULATION OF THE SELF

INTO THE CAPACITY FOR INTERNAL SELF – REGULATION THE NEED TO HOLD ON

INTO THE CAPACITY TO LET GO

Module 8

OPTIMAL STRESS AND

PRECIPITATING DISRUPTION TO TRIGGER REPAIR

THE OPERATIVE CONCEPT HERE IS OPTIMAL STRESS THE THERAPEUTIC USE OF STRESS TO PROVOKE RECOVERY AND GROWTH

WE PRECIPITATE DISRUPTION IN ORDER TO TRIGGER REPAIR AGAINST A BACKDROP OF EMPATHIC ATTUNEMENT AND AUTHENTIC ENGAGEMENT

WE ARE CONTINUOUSLY STRIVING TO FORMULATE INTERVENTIONS THAT WILL EITHER CHALLENGE THEREBY PROVIDING IMPETUS FOR DESTABILIZATION OF THE DYSFUNCTIONAL DEFENSES

OR SUPPORT THEREBY PROVIDING OPPORTUNITY FOR RESTABILIZATION OF THOSE SELF – PROTECTIVE MECHANISMS AT A HIGHER LEVEL OF FUNCTIONALITY AND ADAPTIVE CAPACITY

DESCRIPTION BY CLARE BOOTHE LUCE OF ELEANOR ROOSEVELT AS SOMEONE WHO “COMFORTED THE DISTRESSED” BUT “DISTRESSED THE COMFORTABLE” (FREEDMAN 1967) AS SOMEONE WHO SUPPORTED THOSE WHO NEEDED COMFORT BUT CHALLENGED THOSE WHO DID NOT

WITH THE THERAPIST’S FINGER EVER ON THE PULSE OF THE PATIENT’S LEVEL OF ANXIETY AND CAPACITY TO TOLERATE FURTHER CHALLENGE

THE THERAPIST WILL THEREFORE

CHALLENGE WHEN POSSIBLE BY DIRECTING THE PATIENT’S ATTENTION TO WHERE THE PATIENT IS NOT AND

SUPPORT WHEN NECESSARY BY RESONATING WITH WHERE THE PATIENT IS

CHALLENGE BY WAY OF ANXIETY – PROVOKING INTERPRETIVE STATEMENTS THAT CALL INTO QUESTION DEFENSES TO WHICH THE PATIENT HAS LONG CLUNG IN ORDER TO PRESERVE HER PSYCHOLOGICAL EQUILIBRIUM

THEREBY INCREASING HER ANXIETY

SUPPORT BY WAY OF ANXIETY – ASSUAGING EMPATHIC STATEMENTS THAT HONOR THOSE SELF – PROTECTIVE DEFENSES

THEREBY DECREASING HER ANXIETY

WHEN DO WE CHALLENGE? WHEN WE SENSE THAT WE HAVE A WINDOW OF OPPORTUNITY TO CONFRONT THE PATIENT ABOUT SOMETHING THAT WE KNOW WILL MAKE HER ANXIOUS BUT THAT WE HOPE WILL ULTIMATELY PROVIDE THE IMPETUS FOR HER RECOVERY

WHEN DO WE SUPPORT? WHEN WE SENSE THAT THE PATIENT NEEDS US TO BACK OFF A LITTLE BECAUSE WE HAVE MADE HER TOO ANXIOUS

AS AN EXAMPLE

WE MIGHT FIRST CHALLENGE BY HIGHLIGHTING WHAT THE PATIENT IS COMING TO RECOGNIZE AS A DISILLUSIONING TRUTH ABOUT THE OBJECT OF HER DESIRE

BUT THEN WE WOULD SUPPORT BY RESONATING EMPATHICALLY WITH HER INVESTMENT IN HOLDING ON TO HER HOPE THAT PERHAPS SOMEDAY, SOMEHOW, SOMEWAY, WERE SHE TO BE GOOD ENOUGH, TRY HARD ENOUGH, BE PERSUASIVE ENOUGH, PERSIST LONG ENOUGH, OR SUFFER DEEPLY ENOUGH, SHE MIGHT YET BE ABLE TO MAKE HER BOYFRIEND FALL IN LOVE WITH HER

AGAIN

OPTIMALLY STRESSFUL INTERVENTIONS THAT BOTH CHALLENGE AND SUPPORT

ARE SPECIFICALLY DESIGNED TO PROVOKE JUST THE RIGHT LEVEL OF ANXIETY AND DESTABILIZING / INCENTIVIZING STRESS

THAT IS, OPTIMAL STRESS SUCH THAT THE POTENTIAL FOR TRANSFORMATION AND GROWTH WILL BE OPTIMIZED

REVIEW

IN REACTION / RESPONSE TO OPTIMALLY STRESSFUL INPUT THE PATIENT HERE VIEWED AS A SELF – ORGANIZING (CHAOTIC) SYSTEM

WILL EVOLVE THROUGH HEALING CYCLES OF DESTABILIZATION IN REACTION TO THE THERAPIST’S CHALLENGE

AND THEN IN RESPONSE TO THE THERAPIST’S SUPPORT

RESTABILIZATION AT EVER – HIGHER LEVELS OF FUNCTIONALITY AND ADAPTIVE CAPACITY

Module 9

THREE MODES OF THERAPEUTIC ACTION AND

THREE OPTIMAL STRESSORS

BOTH REVIEW AND PREVIEW

THREE MODES OF THERAPEUTIC ACTION THREE APPROACHES TO TRANSFORMING DEFENSE INTO ADAPTATION THREE OPTIMAL STRESSORS THAT WILL FACILITATE THIS “ACTION” MODEL 1 – TRANSFORMATION OF

RESISTANCE INTO AWARENESS AND ACTUALIZATION OF POTENTIAL BY WORKING THROUGH THE STRESS OF COGNITIVE DISSONANCE RESULTING FROM THE EXPERIENCE OF GAIN – BECOME – PAIN MODEL 2 – TRANSFORMATION OF

RELENTLESSNESS INTO ACCEPTANCE BY WORKING THROUGH THE STRESS OF AFFECTIVE DISILLUSIONMENT RESULTING FROM THE EXPERIENCE OF GOOD – BECOME – BAD MODEL 3 – TRANSFORMATION OF

RE – ENACTMENT INTO ACCOUNTABILITY BY WORKING THROUGH THE STRESS OF RELATIONAL DETOXIFICATION RESULTING FROM THE EXPERIENCE OF BAD – BECOME – GOOD

MUTUALLY ENHANCING NOT MUTUALLY EXCLUSIVE

THREE MODES OF THERAPEUTIC ACTION MODEL 1

THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS THE BEST EXEMPLAR OF WHICH IS FREUD

MODEL 2

THE CORRECTIVE – PROVISION PERSPECTIVE OF SELF PSYCHOLOGY AND THOSE OBJECT RELATIONS THEORIES EMPHASIZING INTERNAL ABSENCE OF GOOD THE BEST EXEMPLARS OF WHICH ARE KOHUT AND BALINT

MODEL 3

THE INTERSUBJECTIVE PERSPECTIVE OF CONTEMPORARY RELATIONAL THEORY AND THOSE OBJECT RELATIONS THEORIES EMPHASIZING INTERNAL PRESENCE OF BAD THE BEST EXEMPLARS OF WHICH ARE FAIRBAIRN AND MITCHELL

MODEL 1 – KNOWLEDGE 1 – PERSON PSYCHOLOGY FOCUS ON PATIENT’S INTERNAL DYNAMICS (1) THERAPIST AS NEUTRAL OBJECT (0)

MODEL 2 – EXPERIENCE 1½ – PERSON PSYCHOLOGY FOCUS ON PATIENT’S AFFECTIVE EXPERIENCE (1) THERAPIST AS EMPATHIC SELFOBJECT OR GOOD OBJECT (½)

MODEL 3 – RELATIONSHIP 2 – PERSON PSYCHOLOGY FOCUS ON PATIENT’S RELATIONAL DYNAMICS (1) THERAPIST AS AUTHENTIC SUBJECT (1)

MODEL 1 – COGNITIVE ENHANCEMENT OF KNOWLEDGE “WITHIN” ULTIMATELY, A STRONGER, WISER, AND MORE EMPOWERED EGO

MODEL 2 – AFFECTIVE PROVISION OF CORRECTIVE EXPERIENCE “FOR” ULTIMATELY, A MORE CONSOLIDATED, ACCEPTING, AND COMPASSIONATE SELF

MODEL 3 – RELATIONAL ENGAGEMENT IN AUTHENTIC RELATIONSHIP “WITH” ULTIMATELY, A MORE PRESENT AND MORE ACCOUNTABLE SELF – IN – RELATION

AS WE SHALL SOON SEE

THE THERAPEUTIC ACTION IN ALL THREE MODES INVOLVES TRANSFORMATION OF DEFENSE INTO ADAPTATION BY FACILITATING THE PATIENT’S PROCESSING AND INTEGRATING OF STRESSFUL LIFE EXPERIENCES PAST AND PRESENT

INCLUDING SOME OF THE THERAPIST’S INTERVENTIONS MODEL 1

WHERE RESISTANCE WAS, THERE SHALL AWARENESS AND ACTUALIZATION OF POTENTIAL BE MODEL 2

WHERE RELENTLESSNESS WAS, THERE SHALL ACCEPTANCE BE MODEL 3

WHERE RE – ENACTMENT WAS, THERE SHALL ACCOUNTABILITY BE

AND AS WE SHALL SOON SEE

THE THERAPEUTIC ACTION IN ALL THREE MODES WILL INVOLVE WORKING THROUGH THE OPTIMAL STRESS CREATED BY INTERVENTIONS THAT ALTERNATELY CHALLENGE AND THEN SUPPORT

INTERVENTIONS STRATEGICALLY DESIGNED TO TARGET AND HIGHLIGHT

MODEL 1 – COGNITIVE DISSONANCE MODEL 2 – AFFECTIVE DISILLUSIONMENT MODEL 3 – RELATIONAL DETOXIFICATION THE WORKING THROUGH OF WHICH WILL RESULT ULTIMATELY IN RECONSTITUTION AT EVER – HIGHER LEVELS OF AWARENESS / ACTUALIZATION OF POTENTIAL, ACCEPTANCE, AND ACCOUNTABILITY

MATURITY INVOLVES DEVELOPING THE CAPACITY …

MODEL 1 TO KNOW AND ACCEPT THE SELF, INCLUDING ITS PSYCHIC SCARS

MODEL 2 TO KNOW AND ACCEPT THE OBJECT, INCLUDING ITS PSYCHIC SCARS

MODEL 3 TO TAKE RESPONSIBILITY FOR WHAT ONE DELIVERS OF ONESELF INTO RELATIONSHIP AND, MORE GENERALLY, INTO ONE’S LIFE THE RESULT – WISER BUT PERHAPS SOBERED, MORE ACCEPTING BUT PERHAPS SADDER MORE ACCOUNTABLE BUT PERHAPS MORE BURDENED

Module 10

TRAUMATIC FRUSTRATION AND

1 – PERSON vs. 2 – PERSON DEFENSES

THE VILLAIN IN OUR PIECE

TRAUMATIC FRUSTRATION BY THE PARENT AS DRIVE OBJECT (MODEL 1), BY THE PARENT AS EMPATHIC SELFOBJECT OR GOOD OBJECT (MODEL 2), AND BY THE PARENT AS AUTHENTIC SUBJECT OR RELATIONAL OBJECT (MODEL 3)

THE HEROINE IN OUR PIECE

OPTIMAL (NONTRAUMATIC) FRUSTRATION NAMELY, OPTIMAL STRESS

ALTHOUGH THE FOCUS IN EACH IS DIFFERENT

ALL THREE OF MY MODELS INVOLVE AS THEIR STARTING POINT

THE INTERNAL PRICE PAID BY THE CHILD BECAUSE OF TRAUMATIC FRUSTRATION BY THE PARENT MODEL 1

REINFORCEMENT OF INFANTILE NEED IN THE FACE OF ITS TRAUMATIC FRUSTRATION MODEL 2

FAILURE TO INTERNALIZE GOOD IN THE FACE OF TRAUMATIC DISILLUSIONMENT MODEL 3

INTROJECTION OF BAD IN THE FACE OF TRAUMATIC INSULT AND INJURY

THE STARTING POINT IN MODEL 1 DEFENSIVELY REINFORCED INFANTILE (LIBIDINAL AND AGGRESSIVE) DRIVES RESULTING FROM THE DRIVE OBJECT PARENT’S EARLY – ON TRAUMATIC FRUSTRATION OF THE CHILD’S AGE – APPROPRIATE (ID) DRIVES

THE THERAPEUTIC ACTION WILL INVOLVE WORKING THROUGH OPTIMAL FRUSTRATION OF THE PATIENT’S INTENSIFIED (AND DEFENDED AGAINST) DRIVES AS THEY ARISE IN THE CONTEXT OF THE TREATMENT WHICH WILL ULTIMATELY RESULT IN ADAPTIVE INTEGRATION OF THOSE (ID) DRIVES NOW TAMED AND MODIFIED

INTO HEALTHY PSYCHIC (EGO) STRUCTURE WHICH WILL THEN ALLOW FOR THE REDIRECTING OF THEIR NOW BETTER REGULATED ENERGY INTO MORE CONSTRUCTIVE PURSUITS AND ACTUALIZATION OF POTENTIAL BY A NOW MORE SKILLED EGO DRIVE (HORSE) AND DEFENSE (RIDER) NO LONGER WORKING IN CONFLICT BUT IN COLLABORATION

THE STARTING POINT IN MODEL 2 STRUCTURAL DEFICIT AND IMPAIRED CAPACITY RESULTING FROM THE SELFOBJECT PARENT’S EARLY – ON TRAUMATIC FRUSTRATION OF THE CHILD’S AGE – APPROPRIATE (NARCISSISTIC) NEED TO HAVE A PERFECT PARENT

THE THERAPEUTIC ACTION WILL INVOLVE WORKING THROUGH OPTIMAL FRUSTRATION OF THE PATIENT’S INTENSIFIED (AND DEFENDED AGAINST) NARCISSISTIC NEED TO FIND THE PERFECT PARENT AS IT ARISES IN THE CONTEXT OF THE RELATIONSHIP WITH THE SELFOBJECT THERAPIST WHICH WILL ULTIMATELY RESULT IN ADAPTIVE TRANSMUTING (STRUCTURE – BUILDING) INTERNALIZATIONS WHICH WILL THEN ALLOW FOR THE FILLING IN OF STRUCTURAL DEFICIT, DEVELOPMENT OF A MORE ROBUST CAPACITY TO BE A GOOD PARENT UNTO ONESELF, ACCRETION OF HEALTHY PSYCHIC STRUCTURE, AND CONSOLIDATION OF A MORE COHESIVE SELF GRIEVING OPTIMAL DISILLUSIONMENT WILL TRANSFORM THE DEFENSIVE NEED FOR EXTERNAL REGULATION OF THE SELF INTO THE ADAPTIVE CAPACITY TO BE INTERNALLY SELF – REGULATING

THE STARTING POINT IN MODEL 3 INTERNAL DEMONS AND A SENSE OF INNER BADNESS RESULTING FROM INTROJECTION OF THE DYSFUNCTIONAL RELATIONAL DYNAMIC CHARACTERIZING THE CHILD’S EARLY – ON RELATIONSHIP WITH THE TRAUMATICALLY ABUSIVE PARENT INTERNAL BAD OBJECTS / PATHOGENIC INTROJECTS

THE THERAPEUTIC ACTION WILL INVOLVE WORKING THROUGH THE TURBULENCE THAT WILL INEVITABLY ARISE AT THE “INTIMATE EDGE” (EHRENBERG 1992) OF AUTHENTIC RELATEDNESS ONCE THE PATIENT DELIVERS HER PATHOGENIC INTROJECTS INTO THE RELATIONSHIP WITH HER THERAPIST WHICH WILL ULTIMATELY RESULT IN GRADUAL MODIFICATION OF THEIR TOXICITY BY WAY OF SERIAL DILUTIONS WHICH WILL THEN ALLOW FOR TRANSFORMATION OF THE DEFENSIVE NEED TO RE – ENACT UNMASTERED EARLY – ON RELATIONAL TRAUMAS INTO THE ADAPTIVE CAPACITY TO HOLD ONESELF ACCOUNTABLE AND TO ENGAGE IN HEALTHY, AUTHENTIC RELATEDNESS

IN THOSE MOMENTS WHEN THE SPOTLIGHT IS ON THE PATIENT AS CONFLICTED, JAMMED UP, OR NEUROTIC BECAUSE OF INTERNAL / STRUCTURAL / INTRAPSYCHIC CONFLICT BETWEEN GROWTH – PROMOTING BUT ANXIETY – PROVOKING FORCES PRESSING “YES” AND ANXIETY – ASSUAGING BUT GROWTH – IMPEDING DEFENSIVE COUNTERFORCES PROTESTING “NO”

THE INTERPRETIVE PERSPECTIVE OF MODEL 1 WILL BE A USEFUL WAY TO CONCEPTUALIZE THE THERAPEUTIC ACTION

IN THOSE MOMENTS WHEN THE SPOTLIGHT IS ON THE PATIENT AS NEEDY, NARCISSISTICALLY VULNERABLE, OR ALWAYS LOOKING TO THE OUTSIDE FOR EXTERNAL PROVISION AND REINFORCEMENT BECAUSE OF AN IMPAIRED CAPACITY TO BE A GOOD PARENT UNTO HERSELF

THE CORRECTIVE – PROVISION DEFICIENCY – COMPENSATION

PERSPECTIVE OF MODEL 2 WILL BE A USEFUL WAY TO CONCEPTUALIZE THE THERAPEUTIC ACTION

IN THOSE MOMENTS WHEN THE SPOTLIGHT IS ON THE PATIENT AS REPLAYING WITH EACH NEW OBJECT THE ONLY KIND OF (DYSFUNCTIONAL) RELATIONSHIP SHE HAS EVER KNOWN AND / OR AS DISAVOWING (TOXIC) ASPECTS OF HER “SELF” AND PROJECTING THEM ONTO HER “OBJECTS” THE CONTEMPORARY RELATIONAL PERSPECTIVE OF MODEL 3 WILL BE A USEFUL WAY TO CONCEPTUALIZE THE THERAPEUTIC ACTION

1 – PERSON vs. 2 – PERSON DEFENSES MODEL 1 FOCUSES ON INTRAPSYCHIC (1 – PERSON) DEFENSES MOBILIZED BY THE EGO IN AN EFFORT TO PROTECT ITSELF AGAINST THREATENED BREAKTHROUGH OF DYSREGULATED AND ANXIETY – PROVOKING ID FORCES THE IMPORTANT RELATIONSHIP IS THE ONE BETWEEN EGO AND ID

MODEL 2 FOCUSES ON INTERPERSONAL (2 – PERSON) DEFENSES MOBILIZED BY THE SELF IN AN EFFORT TO PROTECT ITSELF AGAINST BEING DISAPPOINTED BY ITS SELFOBJECTS THE IMPORTANT RELATIONSHIP IS THE ONE BETWEEN SELF AND SELFOBJECT

MODEL 3 FOCUSES ON INTERPERSONAL (2 – PERSON) DEFENSES MOBILIZED BY THE SELF – IN – RELATION IN AN EFFORT TO PROTECT ITSELF AGAINST BEING ABUSED BY ITS OBJECTS THE IMPORTANT RELATIONSHIP IS THE ONE BETWEEN SELF – IN – RELATION AND RELATIONAL OBJECT

MODEL 1

THE INTERPRETIVE PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS A 1 – PERSON PSYCHOLOGY

THAT FOCUSES ON THE PATIENT’S INTERNAL DYNAMICS AND POSITS INSIGHT, WISDOM, AWARENESS, EMPOWERMENT, AND ACTUALIZATION OF INHERITED POTENTIAL AS THE ULTIMATE THERAPEUTIC GOAL MODEL 2

THE CORRECTIVE – PROVISION PERSPECTIVE OF SELF PSYCHOLOGY AND OTHER DEFICIT THEORIES A 1½ – PERSON PSYCHOLOGY

THAT FOCUSES ON THE PATIENT’S AFFECTIVE EXPERIENCE AND POSITS ACCEPTANCE OF THE OBJECT’S LIMITATIONS, SEPARATENESS, AND IMMUTABILITY AS THE ULTIMATE THERAPEUTIC GOAL MODEL 3

THE CONTEMPORARY RELATIONAL PERSPECTIVE A 2 – PERSON PSYCHOLOGY

THAT FOCUSES ON THE PATIENT’S RELATIONAL DYNAMICS AND POSITS ACCOUNTABILITY AS THE ULTIMATE THERAPEUTIC GOAL

THE TRIUNE BRAIN

(MacLean 1990)

THREE EVOLUTIONARILY DISTINCT STRUCTURES BUT INTERDEPENDENT AND INTERACTIVE WITH ONE ANOTHER

NEOCORTEX (NEW BRAIN) COGNITIVE THE TOP LAYER OF THE CEREBRAL HEMISPHERES

CORRESPONDS TO MODEL 1

LIMBIC SYSTEM (MAMMALIAN BRAIN) EMOTIONAL HIPPOCAMPI – AMYGDALAE – HYPOTHALAMUS

CORRESPONDS TO MODEL 2

REPTILIAN COMPLEX (OLD BRAIN) VISCERAL / INSTINCTUAL BRAINSTEM – CEREBELLUM

CORRESPONDS TO MODEL 3 TOP – DOWN vs. BOTTOM – UP PROCESSING OF INFORMATION AND ENERGY

Module 11

THERAPEUTIC INDUCTION OF HEALING CYCLES OF DISRUPTION AND REPAIR

ALTHOUGH EACH OF THESE THREE MODES OF THERAPEUTIC ACTION PRIVILEGES A DIFFERENT FACET OF THE HEALING PROCESS, WHAT ALL THREE INTERDEPENDENT MODES HAVE IN COMMON IS THEIR USE OF OPTIMALLY STRESSFUL (ANXIETY – PROVOKING BUT ULTIMATELY GROWTH – PROMOTING)

INTERVENTIONS, THE WORKING THROUGH AND MASTERY OF WHICH WILL PROVOKE GRADUATED TRANSFORMATION OF UNHEALTHY, LESS – EVOLVED DEFENSE INTO HEALTHIER, MORE – EVOLVED ADAPTATION

MODEL 1 A DRIVE – DEFENSE MODEL THAT FOCUSES ON THE PATIENT’S UNMODULATED DRIVES AND SELF – PROTECTIVE DEFENSES A MODEL THAT OFFERS THE NEUROTICALLY CONFLICTED PATIENT AN OPPORTUNITY TO GAIN GREATER SELF – AWARENESS AND INSIGHT INTO HER INNER WORKINGS SO THAT SHE CAN MAKE MORE INFORMED DECISIONS ABOUT HER LIFE, BECOME MORE MASTER OF HER DESTINY, AND CHANNEL HER NOW MORE MODULATED ENERGIES INTO ACTUALIZED POTENTIAL

MODEL 2 A MORE CONTEMPORARY PERSPECTIVE THAT FOCUSES ON THE PATIENT’S PSYCHOLOGICAL DEFICIENCIES, THESE PSYCHIC SCARS THE RESULT OF EARLY – ON ABSENCE OF GOOD IN THE FORM OF PARENTAL DEPRIVATION AND NEGLECT THIS MODEL OFFERS THE NARCISSISTICALLY VULNERABLE PATIENT AN OPPORTUNITY IN THE CONTEXT OF THE HERE – AND – NOW RELATIONSHIP WITH HER THERAPIST

BOTH TO GRIEVE THE EARLY – ON PARENTAL FAILURES AND TO EXPERIENCE SYMBOLIC RESTITUTION

MODEL 2

(CONTINUED)

AS THE PATIENT MAKES HER PEACE WITH THE REALITY THAT THE PEOPLE IN HER WORLD WERE NOT, AND WILL NEVER BE, ALL THAT SHE WOULD HAVE WANTED THEM TO BE, SHE WILL EVOLVE TO A PLACE OF GREATER ACCEPTANCE AND INNER SERENITY SADDER PERHAPS, BUT MORE AT PEACE

MODEL 3 ANOTHER CONTEMPORARY PERSPECTIVE THAT FOCUSES ON THE PATIENT’S PSYCHOLOGICAL TOXICITIES, THESE PSYCHIC SCARS THE RESULT OF EARLY – ON PRESENCE OF BAD IN THE FORM OF PARENTAL TRAUMA AND ABUSE THIS MODEL OFFERS THE RELATIONALLY CONFLICTED PATIENT AN OPPORTUNITY IN THE CONTEXT OF THE HERE – AND – NOW RELATIONSHIP WITH HER THERAPIST

SYMBOLICALLY TO PLAY OUT HER UNRESOLVED CHILDHOOD DRAMAS BUT ULTIMATELY TO ENCOUNTER A DIFFERENT RESPONSE THIS TIME

MODEL 3

(CONTINUED)

THE OUTCOME WILL INDEED BE A BETTER ONE BECAUSE THE THERAPIST WILL BE ABLE TO FACILITATE RESOLUTION BY BRINGING TO BEAR HER OWN, MORE – EVOLVED CAPACITY TO PROCESS AND INTEGRATE ON BEHALF OF A PATIENT WHO TRULY DOES NOT KNOW HOW AS THE PATIENT IS CONFRONTED WITH THE SOBERING REALITY OF WHAT SHE HAS BEEN UNCONSCIOUSLY RE – ENACTING IN HER RELATIONSHIPS, SHE WILL EVOLVE TO A PLACE OF GREATER ACCOUNTABILITY FOR HER ACTIONS, REACTIONS, AND INTERACTIONS

WHEN THE THERAPIST WHETHER FUNCTIONING AS NEUTRAL OBJECT, EMPATHIC SELFOBJECT, OR AUTHENTIC SUBJECT

OFFERS OPTIMALLY STRESSFUL INTERVENTIONS THAT PROVIDE JUST THE RIGHT COMBINATION OF CHALLENGE TO PROVIDE IMPETUS

AND SUPPORT TO PROVIDE OPPORTUNITY,

HEALING CYCLES OF DISRUPTION IN REACTION TO THE CHALLENGE

AND REPAIR IN RESPONSE TO THE SUPPORT AND BY TAPPING INTO THE PATIENT’S INNATE “WILL TO RECOVER”

WILL BE INDUCED AND ORDER WILL ULTIMATELY EMERGE FROM CHAOS AS DYSFUNCTIONAL DEFENSE IS GRADUALLY REPLACED BY MORE FUNCTIONAL ADAPTATION

THE THERAPEUTIC ACTION IN ALL THREE PARADIGMS WILL INVOLVE THE THERAPEUTIC INDUCTION OF

HEALING CYCLES OF DISRUPTION AND REPAIR WITH RECONSTITUTION AT EVER – HIGHER LEVELS OF AWARENESS / ACTUALIZATION, ACCEPTANCE, AND ACCOUNTABILITY AS THE PATIENT PROGRESSES NONLINEARLY FROM DISORDEREDNESS TO ORDEREDNESS FROM DYSFUNCTION TO FUNCTIONALITY FROM DEFENSE TO ADAPTATION

TO REPEAT

THE THERAPEUTIC ACTION OF PSYCHODYNAMIC PSYCHOTHERAPY OFFERS THE PATIENT AN OPPORTUNITY ALBEIT A BELATED ONE

TO PROCESS, INTEGRATE, AND ADAPT TO IMPINGEMENTS THAT HAD ONCE BEEN OVERWHELMING AND THEREFORE DEFENDED AGAINST …

… BUT THAT CAN NOW WITHIN THE CONTEXT OF SAFETY PROVIDED BY THE PATIENT’S RELATIONSHIP WITH HER THERAPIST

BE PROCESSED, INTEGRATED, AND ADAPTED TO THEREBY ENABLING THE PATIENT TO EXTRICATE HERSELF FROM THE BONDS OF HER INFANTILE ATTACHMENTS AND HER AMBIVALENTLY CATHECTED DYSFUNCTION

DYSFUNCTIONAL DEFENSE CAN BE REPLACED BY MORE FUNCTIONAL ADAPTATION SUCH THAT

MODEL 1 RESISTANCE TO ACKNOWLEDGING UNCOMFORTABLE TRUTHS ABOUT ONE’S INNER WORKINGS WILL BE REPLACED BY AWARENESS OF THOSE TRUTHS, ULTIMATELY ENABLING ACTUALIZATION OF POTENTIAL

MODEL 2 RELENTLESS HOPE AND REFUSAL TO CONFRONT AND GRIEVE PAINFUL TRUTHS ABOUT THE OBJECT WILL BE REPLACED BY ACCEPTANCE OF THOSE TRUTHS

MODEL 3 COMPULSIVE AND UNWITTING RE – ENACTMENT OF UNRESOLVED CHILDHOOD DRAMAS WILL BE REPLACED BY ACCOUNTABILITY FOR ONE’S ACTIONS, REACTIONS, AND INTERACTIONS

Module 12

AMBIVALENT ATTACHMENT TO DYSFUNCTIONAL DEFENSE AND

NEUROTICALLY CONFLICTED ABOUT HEALTHY DESIRE

MODEL 1 THE INTERPRETIVE, INSIGHT – ORIENTED PERSPECTIVE OF CLASSICAL PSYCHOANALYSIS A 1 – PERSON PSYCHOLOGY FOCUS ON THE PATIENT AND HER INTERNAL WORKINGS

THE TRUTH WILL SET THE PATIENT FREE

JACQUES LACAN’S PITHY STATEMENT THAT THE PATIENT GETS BETTER ONCE THE PATIENT COMES TO KNOW ALL THAT THE ANALYST KNOWS, WHICH IS WHAT THE PATIENT HAD UNCONSCIOUSLY KNOWN ALL ALONG (LACAN 2007)

WHEREAS CLASSICAL PSYCHOANALYSTS TEND TO FOCUS ON INTERNAL CONFLICT BETWEEN ANXIETY – PROVOKING ID DRIVES AND ANXIETY – ASSUAGING EGO DEFENSES I BELIEVE THAT IT IS A LITTLE MORE CLINICALLY USEFUL TO CONCEIVE OF NEUROTIC CONFLICT AS ENCOMPASSING, MORE GENERALLY, GROWTH – IMPEDING TENSION BETWEEN

EMPOWERING BUT ANXIETY – PROVOKING FORCES PRESSING YES

ANXIETY – ASSUAGING (DEFENSIVE) COUNTERFORCES AND

INSISTING NO

BY THE SAME TOKEN

WHEREAS CLASSICAL PSYCHOANALYSTS CONCEIVE OF THE GOAL OF THE WORKING THROUGH PROCESS

AS TAMING THE ID AND STRENGTHENING THE EGO SO THAT DEFENSES WILL NO LONGER BE NECESSARY AND CAN BE RELINQUISHED AND ID – EGO CONFLICTS WILL THEREBY BE RESOLVED

I BELIEVE THAT IT IS A LITTLE MORE CLINICALLY USEFUL TO CONCEIVE OF THE GOAL OF THE WORKING THROUGH PROCESS IN MODEL 1

AS TAMING, MODIFYING, AND INTEGRATING DYSREGULATED BUT ULTIMATELY GROWTH – PROMOTING ID ENERGIES AND EXPOSING TO THE LIGHT OF DAY EGO DEFENSES TO WHICH THE PATIENT IS INTENSELY AND AMBIVALENTLY ATTACHED “INTENSELY” BECAUSE THEY ARE FUELED BY THE “ADHESIVENESS OF THE ID” AND “AMBIVALENTLY” BECAUSE THEY BOTH SERVE HER AND COST HER

SUCH THAT NOW BETTER REGULATED ID ENERGIES CAN BE APPROPRIATED BY A NOW MORE CAPABLE EGO TO FUEL HEALTHIER ENDEAVORS / AMBITIONS THEREBY FACILITATING ACTUALIZATION OF POTENTIAL AS LESS HEALTHY (AMBIVALENTLY CATHECTED) DEFENSES BECOME TRANSFORMED INTO HEALTHIER (MORE INTEGRATED) ADAPTATIONS

IN ESSENCE

THE DYSFUNCTIONAL DEFENSES TO WHICH THE PATIENT IS AMBIVALENTLY ATTACHED LIBIDINALLY BECAUSE THEY SERVE HER AGGRESSIVELY BECAUSE THEY COST HER

WILL UNDERLIE HER PSYCHIC INERTIA AND RESISTANCE TO CHANGE AND INTERFERE WITH HER CAPACITY TO DERIVE PLEASURE AND FULFILLMENT FROM HER LOVE, WORK, AND PLAY BUT BEFORE THESE RESISTIVE COUNTERFORCES CAN BE SURRENDERED, THE PATIENT MUST BECOME AWARE FIRST OF THEIR EXISTENCE AND THEN OF WHAT EXACTLY FUELS THE TENACITY WITH WHICH SHE IS UNWITTINGLY CLINGING TO THEM

AT THE END OF THE DAY

MY PERSPECTIVE IS NOT SO VERY DIFFERENT FROM THE WAY IN WHICH FREUD CONCEIVES OF THE INTRAPSYCHIC SITUATION

EXCEPT THAT MY FOCUS IN MODEL 1 IS ON NOT ONLY HARNESSING THE ID’S EMPOWERING ENERGIES SO THAT THOSE ENERGIES CAN BE INTEGRATED INTO HEALTHY PSYCHIC STRUCTURE

BUT ALSO WORKING THROUGH THE ID’S AMBIVALENT (LIBIDINAL AND AGGRESSIVE) ATTACHMENT TO THE DYSFUNCTIONAL EGO DEFENSES SO THAT THOSE DEFENSES CAN BE RELINQUISHED AND REPLACED BY MORE FUNCTIONAL ADAPTATIONS WHERE ONCE ID AND EGO WERE IN CONFLICT, NOW THE PATIENT WILL BE BETTER ABLE TO HARNESS THE EMPOWERING ID ENERGIES TO FUEL FORWARD MOMENTUM AND ACTUALIZATION OF POTENTIAL

MODEL 1 IN WRITING ABOUT THE CONFLICTUAL RELATIONSHIP THAT EXISTS BETWEEN ID AND EGO, FREUD LIKENS IT TO THE TENSION – FILLED RELATIONSHIP THAT EXISTS BETWEEN A HORSE (ID) AND ITS RIDER (EGO) BUT AS A RESULT OF THE WORKING THROUGH PROCESS WHICH TAMES THE ID AND STRENGTHENS THE EGO

THE HORSE WILL INDEED BECOME TAMER AND THEREFORE MORE MANAGEABLE AND ITS RIDER STRONGER AND THEREFORE MORE ADEPT AT MANAGING HORSE AND RIDER WILL NOW BE BETTER ABLE TO COORDINATE THEIR EFFORTS TO CREATE A SYNERGISTIC RELATIONSHIP THAT IS NO LONGER CONFLICTUAL BUT COLLABORATIVE AND THE DEFENSIVE NEED TO REIN THE HORSE IN WILL HAVE BECOME TRANSFORMED INTO THE ADAPTIVE CAPACITY TO GIVE THE HORSE FREE REIN

CLINICAL VIGNETTE “NEUROTICALLY CONFLICTED ABOUT HEALTHY DESIRE” CONSIDER THE SITUATION OF M.S. WHO WANTS, MORE THAN ANYTHING ELSE IN THE WORLD, TO BE ABLE TO PUT TOGETHER AN ACTION – PACKED POWERPOINT SLIDE SHOW THAT WILL CAPTURE THE ESSENCE OF HER MOST EVOLVED THINKING, TO DATE, ABOUT THE THERAPEUTIC PROCESS BUT SHE IS ALL JAMMED UP ABOUT IT (“NEUROTICALLY CONFLICTED”) AND HAVING A LOT OF TROUBLE GETTING HERSELF TO SIT DOWN TO DO IT AND SO IT IS THAT SHE FINDS HERSELF, WEEKEND AFTER WEEKEND, WATCHING LOTS OF TV AND TAKING LOTS OF NAPS JUST TO AVOID WORKING ON IT

HOW MIGHT WE CONCEIVE OF HER INTERNAL DYNAMICS? ON THE ONE HAND

ARE THE ANXIETY – PROVOKING BUT ULTIMATELY HEALTH – PROMOTING FORCES WITHIN HER THAT ARE CLAMORING FOR EXPRESSION AND RELEASE DYSREGULATED ENERGIES THAT WOULD PROVIDE THE PROPULSIVE FUEL FOR HER FORWARD MOMENTUM WERE SHE BUT ABLE TO HARNESS THEM ENERGIES THAT ARE LITERALLY “CHOMPING AT THE BIT” ON THE OTHER HAND

ARE THE ANXIETY – ASSUAGING BUT GROWTH – IMPEDING DEFENSIVE COUNTERFORCES MOBILIZED BY AN EGO CLEARLY MADE ANXIOUS AND FEELING THE NEED TO REIN IN THE AFOREMENTIONED EMPOWERING ENERGIES

THE DEFENSIVE COUNTERFORCES ARE FUELING M.S.’s PROCRASTINATION BUT AS SHE CONFRONTS HER NEUROTIC CONFLICT ABOUT MOVING FORWARD, SHE COMES TO UNDERSTAND BOTH HOW HER AVOIDANCE IS SERVING HER AND HOW HER AVOIDANCE IS COSTING HER VERY CLEAR TO HER, AT LEAST ON A SUPERFICIAL LEVEL, IS THE PRICE SHE PAYS FOR HER DELAYING

BUT IT IS ONLY OVER TIME, AND AS M.S. BEGINS TO EXPLORE MORE DEEPLY THE REAL REASONS FOR HER PROCRASTINATION, THAT SHE COMES TO THE SOBERING REALIZATION THAT A PIECE OF WHAT IS FUELING HER AVOIDANCE IS THE ENTIRELY UNREALISTIC AND GRANDIOSELY INFANTILE DESIRE TO HAVE HER SLIDE SHOW ENCOMPASS EVERY SINGLE “GOOD IDEA” ABOUT THE THERAPEUTIC ACTION THAT SHE HAS EVER CONCEIVED OVER THE COURSE OF HER CAREER! IT BECOMES CLEAR THAT THE PRIMARY ISSUE UNDERLYING HER PROCRASTINATION, FUELING HER RESISTANCE, AND GETTING HER JAMMED UP IS HER RELUCTANCE TO LET GO OF HER IMPOSSIBLE – TO – ACHIEVE DREAM SO M.S. CONTINUES TO EXPLORE THE DEFENSIVE COUNTERFORCES LURKING DEEP WITHIN THAT ARE INTERFERING WITH HER ABILITY TO MOBILIZE HER ENERGIES SO THAT SHE CAN CHANNEL HER RESOURCES INTO COMPLETING HER SLIDES

IT IS ONLY ONCE M.S. BECOMES AWARE OF JUST HOW ABSURD IT IS FOR HER TO BE STILL HOLDING ON TO HER DEFENSIVE NEED FOR PERFECTION, A NEED THAT IS AT ONCE BOTH SELF – INDULGENT AND SELF – DEFEATING,

THAT THE COGNITIVE DISSONANCE CREATED BY THE TENSION WITHIN HER BETWEEN HER INTENSE DESIRE TO REALIZE HER DREAM AND HER NEW – FOUND APPRECIATION FOR JUST HOW IMPOSSIBLE THAT DREAM REALLY IS FORCES HER TO RELINQUISH HER RELENTLESS PURSUIT A SURRENDER THAT IS ACCOMPANIED BY GRIEVING

AS A RESULT OF CONFRONTING – AND MOURNING – THE LOSS OF THAT DREAM, HOWEVER, M.S.’s NEED FOR PERFECTION BECOMES GRADUALLY TEMPERED INTO A MORE – EVOLVED CAPACITY TO DERIVE PLEASURE AND JOY FROM LOVINGLY CRAFTING A SET OF SLIDES THAT WILL BE AT LEAST “GOOD ENOUGH” M.S. ALSO COMES TO THE LIBERATING REALIZATION THAT NOT EVERY “INSPIRED” IDEA SHE HAS EVER HAD NEEDS TO BE INCLUDED BUT RATHER THAT EVERYTHING INCLUDED NEEDS TO BE AS “INSPIRED” AS POSSIBLE (AND, HOPEFULLY, “INSPIRING”) J

AS HER DIFFICULT – TO – GRATIFY NEED FOR PERFECTION IS GRADUALLY TAMED, MODIFIED, AND INTEGRATED INTO A MORE MANAGEABLE CAPACITY TO TOLERATE IMPERFECTION, M.S. FINDS HERSELF BETTER ABLE TO DIRECT HER NOW MORE MODULATED ENERGIES TOWARDS THE PURSUIT OF NOW MORE REALIZABLE GOALS INTERESTINGLY AND PROBABLY NOT SURPRISINGLY, ALTHOUGH M.S.’s SLIDES DO NOT ULTIMATELY INCLUDE ALL THAT SHE MIGHT ORIGINALLY HAVE WANTED THEM TO, THE NET RESULT OF RELINQUISHING HER COMPULSION TO INCLUDE EVERY “GOOD IDEA” SHE HAS EVER HAD, SO FREES UP HER CREATIVITY THAT SHE FINDS HERSELF ENERGIZED AND NOW ABLE TO GENERATE A LOT OF EXCITING, NEW IDEAS GOING FORWARD! ALL OF WHICH SHE, NO LONGER JAMMED UP, MAKES SURE TO INCLUDE IN HER BOOK OF SLIDES J

AS STRUCTURAL CONFLICT IS TRANSFORMED INTO STRUCTURAL COLLABORATION, THE SYNERGY OF HORSE AND RIDER BECOMES SUCH THAT NOW THEIR EFFORTS CAN BE COORDINATED AND M.S.’s ERSTWHILE DEFENSIVE NEED TO REIN THE HORSE IN MORPHS INTO THE ADAPTIVE CAPACITY TO GIVE THE HORSE FREE REIN

Module 13

GROWTH – PROMOTING BUT

ANXIETY – PROVOKING CONFLICT STATEMENTS

PROTOTYPICAL OPTIMALLY STRESSFUL ANXIETY – PROVOKING BUT ULTIMATELY GROWTH – PROMOTING INTERVENTIONS MODEL 1 CONFLICT STATEMENTS ARE DESIGNED TO ENCOURAGE THE “RESISTANT” PATIENT TO STEP BACK FROM THE IMMEDIACY OF THE MOMENT IN ORDER TO TAKE STOCK OF BOTH HER INVESTMENT IN MAINTAINING THINGS AS THEY ARE AND THE PRICE SHE PAYS FOR DOING SO MODEL 2 DISILLUSIONMENT STATEMENTS ARE DESIGNED TO FACILITATE THE NECESSARY GRIEVING THAT THE “RELENTLESS” PATIENT MUST DO ONCE SHE BEGINS TO CONFRONT HER REFUSAL TO ACCEPT PAINFUL REALITIES ABOUT THE OBJECTS IN HER WORLD MODEL 3 RELATIONAL INTERVENTIONS ARE DESIGNED TO ENCOURAGE THE “RE – ENACTING” PATIENT TO TAKE RESPONSIBILITY FOR THE UNMASTERED CHILDHOOD DRAMAS THAT SHE IS COMPULSIVELY REPLAYING ON THE STAGE OF HER LIFE

MODEL 1 CONFLICT STATEMENTS THE PROCESS OF RENDERING CONSCIOUS WHAT HAD ONCE BEEN UNCONSCIOUS CAN BEST BE FACILITATED THROUGH THE USE OF OPTIMALLY STRESSFUL CONFLICT STATEMENTS THAT ALTERNATELY CHALLENGE AND THEN SUPPORT THEY FIRST CHALLENGE BY SPEAKING TO THE PATIENT’S ADAPTIVE CAPACITY TO KNOW CERTAIN ANXIETY – PROVOKING REALITIES AND THEN WITH COMPASSION AND WITHOUT JUDGMENT

SUPPORT BY RESONATING EMPATHICALLY WITH THE PATIENT’S DEFENSIVE NEED TO DENY KNOWING THOSE UNCOMFORTABLE TRUTHS

THE PATIENT DOES KNOW BE IT SOME PAINFUL TRUTH ABOUT HER INTERNAL DYNAMICS, THE PRICE SHE PAYS FOR MAINTAINING THE STATUS QUO, OR THE THERAPEUTIC WORK SHE HAS YET TO DO

BUT WOULD RATHER NOT

AND SO, MADE ANXIOUS,

SHE DEFENDS

MODEL 1 CONFLICT STATEMENTS STRATEGICALLY DESIGNED TO CREATE DESTABILIZING TENSION WITHIN THE PATIENT BETWEEN HER KNOWLEDGE OF ANXIETY – PROVOKING BUT ULTIMATELY GROWTH – PROMOTING (AND EMPOWERING) REALITIES AND THE DEFENSES SHE MOBILIZES IN ORDER TO EASE THAT ANXIETY THEIR FORMAT

“YOU KNOW THAT …, BUT YOU FIND YOURSELF …” FIRST THE THERAPIST CHALLENGES BY HIGHLIGHTING AN ANXIETY – PROVOKING REALITY AND THEN SUPPORTS BY SPEAKING TO THE PATIENT’S ANXIETY – ASSUAGING DEFENSE

MODEL 1 CONFLICT STATEMENTS “YOU KNOW THAT …, BUT YOU FIND YOURSELF …”

THE THERAPIST FIRST CHALLENGES BY SPEAKING DIRECTLY TO THE PATIENT’S OBSERVING EGO AND ADAPTIVE CAPACITY TO KNOW SOME PAINFUL TRUTH WHICH WILL INCREASE THE PATIENT’S ANXIETY

BUT THEN SUPPORTS BY RESONATING EMPATHICALLY WITH THE PATIENT’S EXPERIENCING EGO AND DEFENSIVE NEED TO DENY SUCH KNOWING WHICH WILL DECREASE THE PATIENT’S ANXIETY

THE PATIENT DOES KNOW “BUT” WOULD RATHER NOT AND SO IT IS THAT SHE, MADE ANXIOUS, DEFENDS AND “FINDS HERSELF” THINKING, FEELING, OR DOING WHATEVER SHE NEEDS TO IN ORDER TO MAINTAIN THINGS AS THEY ARE

IN THE ARMAMENTARIUM OF THE MODEL 1 THERAPIST

AWARENESS – PROMOTING BUT ANXIETY – PROVOKING INTERVENTIONS FIRST THE REALITY (THAT IS, WHAT THE PATIENT REALLY DOES KNOW) AND THEN THE DEFENSE OR RESISTANCE (AND WHAT FUELS IT) YOU KNOW THAT ULTIMATELY YOU’LL NEED TO LET JOSE GO BECAUSE HE, LIKE YOUR DAD, REALLY ISN’T AVAILABLE IN THE WAY THAT YOU WOULD HAVE WANTED HIM TO BE; BUT, FOR NOW, ALL YOU CAN THINK ABOUT IS HOW DESPERATELY YOU WANT TO BE WITH HIM AND HOW HORRIBLE IT WOULD BE TO LOSE HIM. YOU KNOW THAT EVENTUALLY YOU’LL NEED TO MAKE YOUR PEACE WITH THE REALITY OF JUST HOW LIMITED YOUR MOTHER IS; BUT YOUR FEAR IS THAT WERE YOU EVER TO LET YOURSELF REALLY FEEL THE PAIN OF THAT, YOU WOULD NEVER RECOVER. YOU KNOW THAT SOMEDAY YOU’LL HAVE TO LET SOMEBODY IN IF YOU’RE EVER TO HAVE A MEANINGFUL RELATIONSHIP; BUT, IN THE MOMENT, THE THOUGHT OF MAKING YOURSELF THAT VULNERABLE IS ABSOLUTELY INTOLERABLE. THERE’S NO WAY YOU’RE WILLING TO RUN THE RISK OF BEING HURT EVER AGAIN.

MODEL 1 CONFLICT STATEMENTS ANXIETY – PROVOKING BUT ULTIMATELY GROWTH – PROMOTING PSYCHOTHERAPEUTIC INTERVENTIONS

STRATEGICALLY FORMULATED TO PRECIPITATE DISRUPTION IN ORDER TO TRIGGER REPAIR THESE OPTIMALLY STRESSFUL STATEMENTS CALL THE PATIENT’S ATTENTION TO THE CONFLICT THAT EXISTS WITHIN HER BETWEEN THE OBJECTIVE REALITY THAT SHE KNOWS WITH HER HEAD AND THE SUBJECTIVE EXPERIENCE THAT SHE FEELS WITH HER HEART ULTIMATELY, AND MOST IMPORTANTLY, THESE CONFLICT STATEMENTS WILL HIGHLIGHT THE PRICE THE PATIENT IS PAYING FOR REMAINING SO DEEPLY ENTRENCHED IN HER (DYSFUNCTIONAL) STATUS QUO EVEN AS THEY WILL ALSO RESONATE EMPATHICALLY WITH HER INVESTMENT IN MAINTAINING THAT STATUS QUO EVEN SO

8

OPTIMALLY STRESSFUL

MODEL 1 CONFLICT STATEMENTS THAT ALTERNATELY CHALLENGE AND THEN SUPPORT YOU KNOW THAT ULTIMATELY YOU WILL NEED TO CONFRONT – AND GRIEVE – THE REALITY THAT TOM IS NOT AVAILABLE IN THE WAYS THAT YOU WOULD HAVE WANTED HIM TO BE AND THAT UNTIL YOU MAKE YOUR PEACE WITH THAT PAINFUL REALITY YOU WILL CONTINUE TO BE MISERABLE; BUT, IN THE MOMENT, ALL YOU CAN THINK ABOUT IS HOW ANGRY YOU ARE THAT HE DOESN’T TELL YOU MORE OFTEN THAT HE LOVES YOU. YOU KNOW THAT YOU WON’T FEEL TRULY FULFILLED UNTIL YOU ARE ABLE TO GET YOUR THESIS COMPLETED; BUT YOU CONTINUE TO STRUGGLE, FEARING THAT WHATEVER YOU MIGHT WRITE JUST WOULDN’T BE GOOD ENOUGH OR CAPTURE WELL ENOUGH THE ESSENCE OF WHAT YOU ARE WANTING TO SAY. YOU KNOW THAT IF YOUR RELATIONSHIP WITH ELANA IS TO SURVIVE, YOU WILL NEED TO TAKE AT LEAST SOME RESPONSIBILITY FOR THE PART YOU’RE PLAYING IN THE INCREDIBLY ABUSIVE FIGHTS THAT YOU AND SHE ARE HAVING; BUT YOU TELL YOURSELF THAT IT ISN’T REALLY YOUR FAULT BECAUSE IF SHE WEREN’T SO PROVOCATIVE, THEN YOU WOULDN’T HAVE TO BE SO VINDICTIVE! 9

IN ESSENCE

MODEL 1 CONFLICT STATEMENTS STRIVE TO CREATE INCENTIVIZING TENSION WITHIN THE PATIENT BETWEEN HER DAWNING AWARENESS OF JUST HOW COSTLY HER DEFENSES ARE WITH AN EYE TO MAKING THEM MORE EGO – DYSTONIC

AND HER NEW – FOUND UNDERSTANDING OF JUST HOW INVESTED SHE HAS BEEN IN HOLDING ON TO THEM EVEN SO WITH AN EYE TO HIGHLIGHTING HOW EGO – SYNTONIC THEY ARE ULTIMATELY

THE EVER – INCREASING INTERNAL DISSONANCE RESULTING FROM HER EVER – EVOLVING INSIGHT INTO BOTH THE COST AND THE BENEFIT OF MAINTAINING HER ATTACHMENT TO HER (DYSFUNCTIONAL) DEFENSES WILL GALVANIZE HER TO ACTION IN ORDER TO RESOLVE THE INNER TENSION 10

MODEL 1 CONFLICT STATEMENTS YOU KNOW THAT EVENTUALLY YOU WILL NEED TO FACE THE REALITY THAT YOUR MOTHER WAS NEVER REALLY THERE FOR YOU AND THAT YOU WON’T GET BETTER UNTIL YOU LET GO OF YOUR HOPE THAT MAYBE SOMEDAY YOU’LL BE ABLE TO MAKE HER CHANGE; BUT YOU’RE NOT QUITE YET READY TO DEAL WITH ALL THE PAIN AROUND THAT BECAUSE YOU ARE AFRAID THAT YOU MIGHT NEVER SURVIVE THE HEARTBREAK AND DESPAIR YOU WOULD FEEL WERE YOU TO FACE THAT DEVASTATING REALITY. YOU KNOW THAT YOUR NEED FOR YOUR CHILDREN TO UNDERSTAND YOUR PERSPECTIVE MIGHT BE A BIT UNREALISTIC; BUT YOU TELL YOURSELF THAT YOU HAVE A RIGHT TO THEIR RESPECT – AND THEIR FORGIVENESS. YOU’RE COMING TO UNDERSTAND THAT YOUR ANGER CAN PUT PEOPLE OFF; BUT YOU TELL YOURSELF THAT YOU HAVE A RIGHT TO BE AS ANGRY AS YOU WANT BECAUSE OF HOW MUCH YOU HAVE SUFFERED OVER THE YEARS. YOU KNOW THAT IF YOU ARE EVER TO GET ON WITH YOUR LIFE, YOU WILL HAVE TO LET GO OF YOUR CONVICTION THAT YOUR CHILDHOOD SCARRED YOU FOR LIFE; BUT IT’S HARD NOT TO FEEL LIKE DAMAGED GOODS WHEN YOU GREW UP IN A HORRIBLY ABUSIVE HOUSEHOLD WITH A MEAN AND NASTY MOTHER WHO WAS ALWAYS CALLING YOU A LOSER.

11

Module 14

RECURSIVE CYCLES OF CHALLENGE AND SUPPORT AND

LOCATING THE CONFLICT WITHIN THE PATIENT

TO REVIEW

MODEL 1 CONFLICT STATEMENTS ENCOURAGE THE PATIENT TO STEP BACK FROM THE IMMEDIACY OF THE MOMENT IN ORDER TO FOCUS ON THE UNDERLYING FORCES AND COUNTERFORCES WITHIN HER THAT ARE TYING UP HER ENERGIES AND INTERFERING WITH HER FORWARD MOMENTUM THEY ARE DESIGNED TO TEASE OUT AND, ON THE PATIENT’S BEHALF, ARTICULATE THE CONFLICT WITHIN HER BETWEEN HER VOICE OF REALITY WHICH WILL BE ANXIETY – PROVOKING BUT ULTIMATELY INSIGHT – PROMOTING

AND THE GROWTH – OBSTRUCTING DEFENSIVE COUNTERFORCES THAT SHE MOBILIZES IN AN EFFORT TO EASE HER ANXIETY AND SILENCE THAT VOICE

YOU KNOW THAT YOU’RE PAYING A PRICE FOR CLINGING TO YOUR ANGER (A LOT OF THAT ANGER OLD, FROM WAY BACK); BUT YOU FIND YOURSELF FEELING THAT YOU REALLY DON’T HAVE MUCH OF A CHOICE. YOU WOULD WANT TO BE ABLE TO FORGIVE ME; BUT THE PAIN AND THE HURT GO SO DEEP THAT YOU CAN’T IMAGINE EVER BEING ABLE TRULY TO TRUST ME – OR ANYONE ELSE. YOU KNOW THAT YOU MIGHT WELL LATER REGRET IT; BUT, IN THE MOMENT, ALL YOU CAN THINK ABOUT IS HOW GOOD IT WOULD FEEL WERE YOU TO HAVE THAT ICE CREAM SUNDAE. YOU KNOW THAT IF YOU ARE REALLY SERIOUS ABOUT FINDING YOURSELF A PARTNER, THEN YOU WILL NEED TO PUT YOURSELF OUT THERE IN A WAY THAT YOU DON’T ORDINARILY DO; BUT YOU FIND YOURSELF HOLDING BACK BECAUSE YOU HAVE AN UNDERLYING CONVICTION THAT NO MATTER HOW HARD YOU MIGHT TRY, IT WOULDN’T REALLY MAKE ANY DIFFERENCE ANYWAY. YOU KNOW THAT EVENTUALLY, IF YOU ARE EVER TO WORK THROUGH YOUR FEARS OF INTIMACY, YOU WILL HAVE TO LET SOMEONE IN; BUT, RIGHT NOW, YOU’RE FEELING THAT YOU SIMPLY CANNOT AFFORD TO BE THAT VULNERABLE. IN THE PAST, WHEN YOU WERE VULNERABLE, ESPECIALLY IN RELATION TO YOUR MOTHER, YOU ALWAYS GOT HURT.

RECURSIVE CYCLES OF

CHALLENGE, THEN SUPPORT ADDRESSING

COGNITIVE, THEN AFFECTIVE HEAD, THEN HEART KNOWLEDGE, THEN EXPERIENCE OBJECTIVE, THEN SUBJECTIVE OBSERVING EGO, THEN EXPERIENCING EGO LEFT BRAIN, THEN RIGHT BRAIN ADAPTIVE CAPACITY, THEN DEFENSIVE NEED ADAPTATION, THEN DEFENSE

WITH THE THERAPIST’S FINGER EVER ON THE PULSE OF THE PATIENT’S LEVEL OF ANXIETY AND CAPACITY TO TOLERATE FURTHER CHALLENGE, MOMENT BY MOMENT

THE THERAPIST WILL ALTERNATELY SUPPORT BY RESONATING WITH WHERE THE PATIENT IS

AND THEN CHALLENGE BY DIRECTING THE PATIENT’S ATTENTION TO ELSEWHERE BACK AND FORTH, BACK AND FORTH FIRST SUPPORT AND CHALLENGE, THEN CHALLENGE AND SUPPORT MOMENT BY MOMENT

THE THERAPIST WILL ALTERNATELY CHALLENGE BY REMINDING THE PATIENT OF AN ANXIETY – PROVOKING REALITY THAT THE PATIENT HAS THE ADAPTIVE CAPACITY TO ACKNOWLEDGE (ALBEIT RELUCTANTLY)

AND THEN SUPPORT BY RESONATING WITH THE PATIENT’S DEFENSIVE NEED TO MAINTAIN THINGS EXACTLY AS THEY ARE

ALL WITH AN EYE TO GENERATING AN OPTIMAL LEVEL OF INCENTIVIZING AND THEREFORE GROWTH – PROMOTING STRESS

PARENTHETICALLY

AS WE SIT WITH OUR PATIENTS, THERE IS ALWAYS A DIALECTICAL TENSION WITHIN US, AS WELL, BETWEEN ON THE ONE HAND

OUR VISION OF WHO WE THINK THE PATIENT COULD BE WERE SHE BUT ABLE TO MAKE HEALTHIER CHOICES

AND ON THE OTHER HAND

OUR RESPECT FOR THE REALITY OF WHO SHE IS AND FOR THE CHOICES, NO MATTER HOW UNHEALTHY, THAT SHE IS CONTINUOUSLY MAKING

WE ARE THEREFORE ALWAYS STRUGGLING TO FIND AN OPTIMAL BALANCE WITHIN OURSELVES BETWEEN WANTING THE PATIENT TO CHANGE AND ACCEPTING THE REALITY OF WHO SHE IS

IMPORTANTLY

MODEL 1 CONFLICT STATEMENTS BY LOCATING WITHIN THE PATIENT THE CONFLICT BETWEEN HER ANXIETY – PROVOKING KNOWLEDGE OF A DISTRESSING REALITY AND HER ANXIETY – ASSUAGING NEED TO DISMISS IT, THE THERAPIST IS DEFTLY SIDESTEPPING THE POTENTIAL FOR CONFLICT BETWEEN THERAPIST AND PATIENT

MODEL 1 CONFLICT STATEMENTS THE THERAPIST WHO IS ABLE TO RESIST THE TEMPTATION TO GET BOSSY BY OVERZEALOUSLY ADVOCATING FOR THE PATIENT TO DO THE “RIGHT THING” WILL BE ABLE MASTERFULLY TO AVOID GETTING DEADLOCKED IN A POWER STRUGGLE WITH THE PATIENT SUCH A STRUGGLE CAN EASILY ENOUGH ENSUE WHEN THE THERAPIST TAKES IT UPON HERSELF TO REPRESENT THE VOICE OF REALITY

A STANCE THAT THEN LEAVES THE PATIENT NO OPTION BUT TO BECOME THE VOICE OF OPPOSITION

WHEN THE THERAPIST INTRODUCES A CONFLICT STATEMENT WITH

“YOU KNOW THAT …” SHE WILL BE FORCING THE PATIENT TO TAKE RESPONSIBILITY FOR WHAT SHE REALLY DOES KNOW BUT IF THE THERAPIST, IN A MISGUIDED ATTEMPT TO URGE THE PATIENT FORWARD, RESORTS SIMPLY TO TELLING THE PATIENT WHAT THE THERAPIST KNOWS, NOT ONLY DOES THE THERAPIST RUN THE RISK OF FORCING THE PATIENT TO BECOME EVER MORE ENTRENCHED IN HER DEFENSIVE STANCE OF PROTEST BUT ALSO THE THERAPIST WILL BE ROBBING THE PATIENT OF ANY INCENTIVE TO TAKE RESPONSIBILITY FOR HER OWN DESIRE TO GET BETTER

IT REALLY IS AN UNTENABLE SITUATION FOR THE THERAPIST TO BE THE ONE REPRESENTING THE HEALTHY (ADAPTIVE) VOICE OF YES AND FOR THE PATIENT, MADE ANXIOUS, TO BE THEN STUCK IN THE POSITION OF HAVING TO COUNTER WITH THE UNHEALTHY (DEFENSIVE) VOICE OF NO AND SO IT IS THAT IN THE FIRST PART OF THE CONFLICT STATEMENT THE THERAPIST HIGHLIGHTS WHAT THE PATIENT, AT LEAST ON SOME LEVEL, REALLY DOES KNOW IN ESSENCE

BY LOCATING THE CONFLICT SQUARELY WITHIN THE PATIENT AND NOT IN THE INTERSUBJECTIVE FIELD BETWEEN THERAPIST AND PATIENT, CONFLICT STATEMENTS FORCE THE PATIENT TO TAKE OWNERSHIP OF BOTH SIDES OF HER AMBIVALENCE ABOUT GETTING BETTER BOTH THE YES FORCES AND THE NO COUNTERFORCES MOBILIZED IN REACTION TO THOSE YES FORCES

ALSO NOTE THE IMPLICIT MESSAGE DELIVERED BY THE THERAPIST IN THE SECOND PART OF A CONFLICT STATEMENT WHEN SHE USES SUCH TEMPORAL EXPRESSIONS AS

“FOR NOW” – “RIGHT NOW” “AT THE MOMENT” – “IN THE MOMENT” “AT THIS POINT IN TIME” WHICH SHE WILL DO WHEN SHE IS ADDRESSING THE PATIENT’S “INVESTMENT IN” THE DYSFUNCTIONAL DEFENSE YOU KNOW YOU’RE PAYING A STEEP PRICE FOR YOUR REFUSAL TO STOP SMOKING, OF PARTICULAR CONCERN BECAUSE OF YOUR RECURRENT LUNG INFECTIONS; BUT, IN THE MOMENT, YOU FIND YOURSELF FEELING THAT YOU SIMPLY MUST HAVE THE CIGARETTES IN ORDER TO RELIEVE THE MASSIVE ANXIETY THAT YOU’RE FEELING BECAUSE OF THE LAWSUIT.

THE THERAPIST IS ATTEMPTING TO HIGHLIGHT THE FACT THAT EVEN IF, FOR NOW, THE PATIENT WOULD SEEM TO BE INVESTED IN PROTESTING HER RIGHT TO MAINTAIN THINGS AS THEY ARE, AT ANOTHER POINT IN TIME THAT COULD CHANGE

IN SUM

OPTIMALLY STRESSFUL CONFLICT STATEMENTS ARE DESIGNED TO PROVOKE THE RELINQUISHMENT OF DYSFUNCTIONAL DEFENSES BY GENERATING COGNITIVE AND AFFECTIVE DISSONANCE IMPORTANTLY

THE WISDOM OF THE BODY IS SUCH THAT IT CANNOT TOLERATE THE DISTRESS OF DISEQUILIBRIUM FOR EXTENDED PERIODS OF TIME AND WILL THEREFORE BE PROMPTED TO TAKE ACTION IN ORDER TO RESOLVE THE TENSION AND RESTORE THE ORDER ULTIMATELY

IT WILL BE THE PATIENT’S EVER – EVOLVING ADAPTIVE CAPACITY TO RECOGNIZE THE FUNDAMENTAL CONFLICT BETWEEN COST AND BENEFIT THAT WILL SIMPLY FORCE HER TO LET GO OF HER DYSFUNCTION

THAT IS, TO SURRENDER HER UNHEALTHY DEFENSES DESPITE THEIR ERSTWHILE ROBUSTNESS

IN FAVOR OF HEALTHIER ADAPTATIONS AS SHE EVOLVES FROM CURSING THE DARKNESS TO LIGHTING A CANDLE

Module 15

COGNITIVE DISSONANCE AND

FROM STRUCTURAL CONFLICT TO STRUCTURAL COLLABORATION

TO SUMMARIZE

IN ORDER TO INCREASE THE PATIENT’S AWARENESS OF HER AMBIVALENT ATTACHMENT TO HER DYSFUNCTIONAL DEFENSES THE MODEL 1 INTERPRETIVE THERAPIST

ALTERNATELY CHALLENGES BY HIGHLIGHTING WHAT THE PATIENT IS COMING TO UNDERSTAND AS THE PRICE SHE PAYS FOR CLINGING TO HER DYSFUNCTIONAL DEFENSES A PRICE THAT FUELS HER AGGRESSIVE CATHEXIS OF THOSE DEFENSES

AND THEN SUPPORTS BY RESONATING WITH WHAT THE THERAPIST IS COMING TO UNDERSTAND AS THE INVESTMENT THE PATIENT HAS IN HOLDING ON TO HER DYSFUNCTIONAL DEFENSES EVEN SO AN INVESTMENT THAT FUELS HER LIBIDINAL CATHEXIS OF THOSE DEFENSES

BACK AND FORTH – BACK AND FORTH

IN AN EFFORT TO MAKE THE AMBIVALENTLY HELD DEFENSE EVER LESS EGO – SYNTONIC AND EVER MORE EGO – DYSTONIC

EVER – INCREASING AWARENESS OF INTERNAL CONFLICT THE GOAL OF THESE OPTIMALLY STRESSFUL INTERVENTIONS IS NOT ONLY TO GIVE THE PATIENT SUFFICIENT SPACE TO EXPERIENCE WHATEVER SHE MIGHT FIND HERSELF FEELING AS A REACTION TO BEING CONFRONTED WITH ANXIETY – PROVOKING REALITIES THAT SHE CAN NO LONGER DENY BUT ALSO TO PROMOTE ENOUGH DETACHMENT THAT SHE WILL BE ABLE TO BRING TO BEAR HER SELF – REFLECTIVE CAPACITY ALL WITH AN EYE TO MAKING HER EVER MORE ACUTELY AWARE OF THE STRUGGLE BEING WAGED WITHIN HER BETWEEN WHAT HER HEAD – ALBEIT BEGRUDGINGLY – KNOWS AND WHAT HER HEART – IN DESPERATE PROTEST – FEELS

BY REPEATEDLY FORMULATING CONFLICT STATEMENTS THAT STRATEGICALLY JUXTAPOSE THE PATIENT’S DAWNING AWARENESS OF JUST HOW STEEP A PRICE SHE IS PAYING FOR HOLDING ON TO HER DEFENSES THAT IS,

THE PAIN

AND HER NEW – FOUND APPRECIATION FOR HOW THEY HAVE SERVED HER THAT IS,

THE GAIN

THE THERAPIST WILL BE ABLE TO CREATE GALVANIZING TENSION WITHIN THE PATIENT

GROWTH – PROMOTING DISSONANCE THAT WILL ULTIMATELY BECOME THE FULCRUM FOR THERAPEUTIC CHANGE

AND SO IT IS THAT THE THERAPIST

WILL REPEATEDLY JUXTAPOSE BOTH

THE “PRICE PAID” (PAIN) AND THE “INVESTMENT IN” (GAIN) IN ORDER INCREMENTALLY TO MAKE THE PATIENT’S AMBIVALENTLY HELD DYSFUNCTIONAL DEFENSES EVER LESS EGO – SYNTONIC THAT IS, EVER LESS CONSONANT WITH WHO SHE WOULD WANT TO BE

AND EVER MORE EGO – DYSTONIC OR EGO ALIEN THAT IS, EVER MORE DISSONANT WITH WHO SHE WOULD WANT TO BE

AS LONG AS THE GAIN IS GREATER THAN THE PAIN, THE PATIENT WILL MAINTAIN THE DEFENSE AND REMAIN ENTRENCHED BUT ONCE THE PAIN BECOMES GREATER THAN THE GAIN, THE STRESS AND STRAIN THEREBY CREATED AS A RESULT OF THE COGNITIVE AND AFFECTIVE DISSONANCE BETWEEN THE PAIN AND THE GAIN WILL PROVIDE THE IMPETUS NEEDED …

… FOR THE PATIENT GRADUALLY TO RELINQUISH HER ATTACHMENT TO THE DEFENSE IN ORDER TO RESTORE HER PSYCHOLOGICAL EQUILIBRIUM THEREBY

RESOLVING STRUCTURAL CONFLICT BETWEEN ID DRIVE AND EGO DEFENSE THE NOW STRONGER EGO WILL BE BETTER ABLE TO REGULATE THE NOW TAMER FORCES OF THE ID BY REDIRECTING THOSE ENERGIES INTO MORE CONSTRUCTIVE CHANNELS IN SUM AS THE EGO BECOMES EMPOWERED AND THE ID ENERGIES ARE HARNESSED,

THE PATIENT’S NEUROTIC CONFLICTEDNESS AND RESULTANT OBSTRUCTED PROGRESSION THROUGH LIFE

WILL BECOME GRADUALLY TRANSFORMED INTO ACTUALIZATION OF POTENTIAL

IN ESSENCE

A WEAK EGO’S NEED TO DEFEND AGAINST THE UNTAMED ENERGIES OF AN ID WILL HAVE BECOME GRADUALLY TRANSFORMED INTO A STRONGER EGO’S CAPACITY TO CHANNEL THOSE NOW TAMER ENERGIES INTO MORE CONSTRUCTIVE PURSUITS IN LANGUAGE PERHAPS MORE FAMILIAR

THE DEFENSIVE NEED TO

“PUT A LID ON THE ID” WILL HAVE BECOME

GRADUALLY TRANSFORMED INTO THE ADAPTIVE CAPACITY TO

“SUBLIMATE” AS CONFLICT IS REPLACED BY COLLABORATION

MODEL 1 HIGHLIGHTS ENHANCED KNOWLEDGE / INSIGHT / WISDOM INCREASED SELF – AWARENESS RENDERING CONSCIOUS THE UNCONSCIOUS INCREASED AWARENESS OF INTERNAL CONFLICT BETWEEN EMPOWERING FORCES AND GROWTH – IMPEDING DEFENSIVE COUNTERFORCES

DEEP APPRECIATION FOR THE AMBIVALENCE OF THE PATIENT’S ATTACHMENT TO THESE RESISTANT COUNTERFORCES MORE SPECIFICALLY, UNDERSTANDING THAT THESE DEFENSES BOTH BENEFIT HER THUS HER LIBIDINAL CATHEXIS OF THEM (AND THE IMPORTANCE OF ADDRESSING HER INVESTMENT IN HAVING THEM)

AND COST HER THUS HER AGGRESSIVE CATHEXIS OF THEM (AND THE IMPORTANCE OF ADDRESSING THE PRICE SHE IS PAYING FOR HAVING THEM)

AN INTENSELY AMBIVALENT ATTACHMENT THAT SPEAKS TO THE ADHESIVENESS OF THE ID AND MUST BE WORKED THROUGH BEFORE THESE DEFENSES CAN BE RELINQUISHED

MODEL 1 HIGHLIGHTS (CONTINUED) THE WORKING THROUGH PROCESS WILL TAME THE ID AND STRENGTHEN THE EGO AND WILL INVOLVE HIGHLIGHTING THE COGNITIVE DISSONANCE BETWEEN THE BENEFIT (GAIN) AND THE COST (PAIN) THEREBY RENDERING THE DEFENSES INCREASINGLY EGO – DYSTONIC AND EVER LESS EGO – SYNTONIC THE OPTIMAL STRESS AND STRAIN OF THIS COGNITIVE DISSONANCE WILL CREATE INCENTIVIZING TENSION THAT WILL ULTIMATELY FORCE SURRENDER OF THE UNHEALTHY DEFENSES IN FAVOR OF HEALTHIER ADAPTATIONS

AND RESOLUTION OF THE STRUCTURAL CONFLICT IN FAVOR OF STRUCTURAL COLLABORATION A TAMER HORSE (ID) AND A STRONGER RIDER (EGO) NOW OPERATING SYNERGISTICALLY

WITH THE FREEING UP OF ENERGIES THAT HAD ONCE BEEN HELD IN CHECK, THE EMPOWERING (ID) ENERGIES CAN NOW BE ADAPTIVELY HARNESSED AND CHANNELED (BY THE EGO) INTO MORE CONSTRUCTIVE PURSUITS, THEREBY FUELING ACTUALIZATION OF POTENTIAL

FROM STRUCTURAL CONFLICT TO STRUCTURAL COLLABORATION FROM “DEFENSE AGAINST” TO “ADAPTING TO”

Module 16

NATURE vs. NURTURE AND

I – IT vs. I – THOU RELATIONSHIPS

WHEREAS THE THERAPEUTIC ACTION IN MODEL 1 INVOLVES WORKING THROUGH THE STRESS OF GAIN – BECOME – PAIN AS DEFENSES ONCE EGO – SYNTONIC ARE MADE INCREASINGLY EGO – DYSTONIC

THE THERAPEUTIC ACTION IN MODEL 2 INVOLVES WORKING THROUGH THE STRESS OF GOOD – BECOME – BAD AS THE PATIENT’S DEFENSIVE NEED TO CLING TO ILLUSION IS CHALLENGED AND GRADUALLY REPLACED BY MORE ACCURATE (AND SOBERING) PERCEPTIONS OF REALITY

THE THERAPEUTIC ACTION IN MODEL 3 INVOLVES WORKING THROUGH THE STRESS OF BAD – BECOME – GOOD

AND

AS THE PATIENT’S DEFENSIVE NEED TO CLING TO DISTORTION BECAUSE THAT IS ALL SHE HAS EVER KNOWN

IS CHALLENGED AND GRADUALLY REPLACED BY MORE ACCURATE (AND LESS TOXIC) PERCEPTIONS OF REALITY

AS HAD BEEN NOTED EARLIER

CLASSICAL PSYCHOANALYSTS CONCEIVE OF PSYCHOPATHOLOGY AS DERIVING FROM THE PATIENT IN WHOM THERE IS THOUGHT TO BE INTERNAL CONFLICT BETWEEN AN UNTAMED ID AND A WEAK EGO

BUT SELF PSYCHOLOGISTS AND OBJECT RELATIONS THEORISTS CONCEIVE OF PSYCHOPATHOLOGY AS DERIVING FROM THE PARENT AND THE PARENT’S TRAUMATIC FAILURE OF THE CHILD

OVERVIEW

WHEREAS CLASSICAL PSYCHOANALYSTS FOCUS ON DEFENSIVE REINFORCEMENT OF INFANTILE DRIVES WHICH THEN GIVES RISE TO INTERNAL CONFLICT BETWEEN INTENSIFIED ID DRIVES AND AN UNDEVELOPED EGO MADE ANXIOUS

SELF PSYCHOLOGISTS FOCUS ON TRAUMATIC PARENTAL ERRORS OF OMISSION THAT CREATE INTERNAL DEFICITS WHICH THEN GIVE RISE TO AN INTENSIFIED NEED TO FIND IN THE HERE – AND – NOW RELATIONSHIP WITH THE THERAPIST THE GOOD PARENT THE PATIENT NEVER HAD CONSISTENTLY AND RELIABLY EARLY – ON

AND OBJECT RELATIONS THEORISTS FOCUS ON TRAUMATIC PARENTAL ERRORS OF COMMISSION THAT CREATE INTERNAL BAD OBJECTS WHICH THEN GIVE RISE TO COMPULSIVE AND UNWITTING RE – ENACTMENTS IN THE HERE – AND – NOW RELATIONSHIP WITH THE THERAPIST OF THE TOXIC RELATIONAL DYNAMICS THAT HAD CHARACTERIZED THE PATIENT’S EARLY – ON RELATIONSHIP WITH HER ABUSIVE PARENT

IN OTHER WORDS

SELF PSYCHOLOGISTS AND OBJECT RELATIONS THEORISTS FOCUS

NOT SO MUCH ON NATURE THE PROVINCE OF MODEL 1

AS ON NURTURE THE PROVINCE OF MODELS 2 AND 3

WHETHER

THE QUALITY OF PARENTAL CARE MODEL 2

OR THE MUTUALITY OF FIT

BETWEEN PARENT AND CHILD MODEL 3

NATURE WHAT DERIVES FROM WITHIN THE CHILD

MODEL 1

NURTURE WHAT DERIVES FROM WITHIN THE RELATIONSHIP BETWEEN PARENT AND CHILD

MODEL 2 AND MODEL 3

BUT PLEASE NOTE THE CRITICAL DISTINCTION BETWEEN QUALITY OF PARENTAL CARE A STORY ABOUT “GIVE”

WHICH MAKES OF MODEL 2 A 1½ – PERSON PSYCHOLOGY

AND MUTUALITY OF FIT A STORY ABOUT “GIVE – AND – TAKE”

WHICH MAKES OF MODEL 3 A 2 – PERSON PSYCHOLOGY

AS THE ETIOLOGY HAS SHIFTED FROM NATURE TO NURTURE, SO TOO THE LOCUS OF THE THERAPEUTIC ACTION HAS SHIFTED FROM “INSIGHT BY WAY OF INTERPRETATION” TO “A CORRECTIVE EXPERIENCE BY WAY OF THE REAL RELATIONSHIP” FROM WITHIN THE PATIENT TO WITHIN THE RELATIONSHIP BETWEEN THERAPIST AND PATIENT THAT IS,

MODEL 2

AN “I – IT” RELATIONSHIP A 1 – WAY RELATIONSHIP BETWEEN SOMEONE WHO GIVES AND SOMEONE WHO TAKES

MODEL 3

AN “I – THOU” RELATIONSHIP A 2 – WAY RELATIONSHIP INVOLVING GIVE – AND – TAKE, MUTUALITY, RECIPROCITY, AND COLLABORATION

(BUBER 1923)

THE EMPHASIS IN MODEL 2 IS NOT SO MUCH ON THE RELATIONSHIP PER SE AS IT IS ON THE FILLING IN OF DEFICIT BY WAY OF THE THERAPIST’S CORRECTIVE PROVISION MORE ACCURATELY

BY WAY OF THE PATIENT’S WORKING THROUGH DISRUPTIONS TO THAT CORRECTIVE PROVISION OCCASIONED BY THE THERAPIST’S INEVITABLE EMPATHIC FAILURES

IN OTHER WORDS

THE THERAPEUTIC ACTION IN MODEL 2 INVOLVES CONFRONTING AND GRIEVING DISAPPOINTMENT THE PATIENT EXPERIENCES IN THE FACE OF FAILURES IN THE THERAPIST’S CORRECTIVE PROVISION OPTIMAL DISILLUSIONMENT AND THE RESULTANT TRANSMUTING INTERNALIZATIONS

AND THE RELATIONSHIP THAT EXISTS BETWEEN A PERSON WHO PROVIDES AND A PERSON WHO IS THE RECIPIENT OF SUCH PROVISION MODEL 2

IS A FAR CRY FROM THE RELATIONSHIP THAT EXISTS BETWEEN TWO REAL PEOPLE MODEL 3 THIS LATTER

AN INTERSUBJECTIVE RELATIONSHIP INVOLVING “RECIPROCALLY MUTUAL INTERACTION”

BETWEEN TWO SUBJECTS BOTH OF WHOM ARE THOUGHT TO CONTRIBUTE TO WHAT TRANSPIRES AT THE INTIMATE EDGE BETWEEN THEM

Module 17

CORRECTIVE PROVISION vs.

AUTHENTIC ENGAGEMENT

AND SO IT IS THAT IN THE PAST 30 YEARS OR SO CONTEMPORARY THEORISTS HAVE BEGUN TO HIGHLIGHT THE CRITICAL DISTINCTION BETWEEN MODEL 2

THE THERAPIST’S PROVISION OF A CORRECTIVE EXPERIENCE AS A NEW GOOD OBJECT

FOR THE PATIENT MODEL 3

THE THERAPIST’S PARTICIPATION IN A REAL RELATIONSHIP AS AN AUTHENTIC SUBJECT

WITH THE PATIENT

MORE SPECIFICALLY, NOTE THE DISTINCTION BETWEEN

THE THERAPIST’S PARTICIPATION AS A NEW GOOD OBJECT

MODEL 2 AND

THE THERAPIST’S PARTICIPATION AS AN AUTHENTIC SUBJECT

MODEL 3 WHICH WILL ALMOST INEVITABLY END UP INVOLVING THE THERAPIST’S PARTICIPATION AS THE OLD BAD OBJECT BECAUSE OF THE PATIENT’S EVER – PRESENT NEED TO RECREATE THE EARLY – ON TRAUMATIC FAILURE SITUATION IN THE HERE – AND – NOW RELATIONSHIP WITH HER THERAPIST IN AN EFFORT TO ACHIEVE BELATED MASTERY

AGAIN

WE ARE SPEAKING HERE TO THE DISTINCTION BETWEEN A MODEL OF THERAPEUTIC ACTION THAT CONCEIVES OF THE THERAPY RELATIONSHIP AS INVOLVING GIVE THE THERAPIST GIVING, THE PATIENT TAKING MODEL 2

AND A MODEL THAT CONCEIVES OF THE THERAPY RELATIONSHIP AS INVOLVING GIVE – AND – TAKE BOTH PARTICIPANTS GIVING AND TAKING MODEL 3

MICHAEL BALINT AN ADVOCATE FOR THE MODEL 2 CORRECTIVE – PROVISION APPROACH

WRITES ABOUT THE “AREA OF THE BASIC FAULT,” WHICH MUST BE “PUT RIGHT”

“IT IS DEFINITELY A TWO – PERSON RELATIONSHIP IN WHICH, HOWEVER, ONLY ONE OF THE PARTNERS MATTERS …” (BALINT 1968)

ALTHOUGH THERE ARE STILL SOME WHO WRITE ABOUT “A CORRECTIVE EXPERIENCE BY WAY OF THE REAL RELATIONSHIP,” THIS TELESCOPES TWO DIFFERENT CONCEPTS AND OBFUSCATES THE CRITICAL CLINICAL DISTINCTION BETWEEN A THERAPY RELATIONSHIP THAT INVOLVES GIVE DISPLACEMENT OF NEED TO FIND NEW GOOD AND THEN WORKING THROUGH POSITIVE TRANSFERENCE DISRUPTED

AND A THERAPY RELATIONSHIP THAT INVOLVES GIVE – AND – TAKE PROJECTION OF NEED TO REFIND OLD BAD AND THEN WORKING THROUGH NEGATIVE TRANSFERENCE

A “CORRECTIVE EXPERIENCE” IN THE FIRST INSTANCE (MODEL 2) A “REAL RELATIONSHIP” IN THE SECOND (MODEL 3)

AGAIN

MODEL 2 THEORISTS FOCUS ON THE PRICE THE CHILD PAYS BECAUSE OF WHAT THE PARENT DID NOT DO DEPRIVATION AND NEGLECT

ABSENCE OF GOOD DEFICIENCY

INTERNALLY RECORDED IN THE FORM OF STRUCTURAL DEFICIT AND IMPAIRED CAPACITY TO BE A GOOD PARENT UNTO ONESELF

A DEFICIT THAT THEN GIVES RISE TO THE SEARCH FOR A NEW GOOD PARENT TO COMPENSATE FOR THE EARLY – ON ERRORS OF OMISSION

IN ESSENCE

THE DEFICIT CREATES THE NEED TO FIND NEW GOOD TO FILL IN FOR MISSING PSYCHIC STRUCTURE AND FUNCTIONAL CAPACITY

ONCE THAT NEED FOR NEW GOOD GETS DELIVERED BY WAY OF DISPLACEMENT

INTO THE THERAPY RELATIONSHIP, A POSITIVE TRANSFERENCE WILL EMERGE WHETHER A MIRROR OR AN IDEALIZING TRANSFERENCE

WORKING THROUGH DISRUPTIONS OF WHICH WILL CONSTITUTE THE THERAPEUTIC ACTION TO BE DISTINGUISHED FROM THE NEGATIVE TRANSFERENCE OF MODEL 3 THAT WILL EMERGE WHEN PATHOGENIC INTROJECTS GET DELIVERED BY WAY OF PROJECTION OR PROJECTIVE IDENTIFICATION

INTO THE THERAPY RELATIONSHIP

AGAIN

MODEL 3 THEORISTS FOCUS ON THE PRICE THE CHILD PAYS BECAUSE OF WHAT THE PARENT DID DO TRAUMA AND ABUSE

PRESENCE OF BAD TOXICITY

INTERNALLY RECORDED AND STRUCTURALIZED IN THE FORM OF PATHOGENIC INTROJECTS MORE SPECIFICALLY, PAIRS OF INTERNAL BAD OBJECTS VICTIMIZER – VICTIM / CRITICIZER – CRITICIZEE / ABANDONER – ABANDONEE

THAT BECOME FILTERS THROUGH WHICH THE PATIENT THEN EXPERIENCES HER WORLD EITHER DISTORTEDLY (BECAUSE OF PROJECTION) OR IN ACTUALITY (BECAUSE OF PROJECTIVE IDENTIFICATION)

MODEL 3 WHEN UNDER THE SWAY OF THE REPETITION COMPULSION

THESE PATHOGENIC INTROJECTS AND DYSFUNCTIONAL “PATTERNS OF RELATIONAL EXPECTATION” (HEDGES 1983) ARE COMPULSIVELY AND UNWITTINGLY RE – PLAYED IN THE THERAPY RELATIONSHIP, A NEGATIVE TRANSFERENCE WILL EMERGE WHETHER THE RESULT OF PROJECTION OR PROJECTIVE IDENTIFICATION

AND THE PATIENT WILL END UP RE – EXPERIENCING THE EARLY – ON TRAUMATIC FAILURE SITUATION AGAIN AND AGAIN

UNTIL SOMETHING DIFFERENT HAPPENS AND THERE CAN BE RESOLUTION OF THE DYSFUNCTIONAL RELATIONAL DYNAMIC, ACCOMPANIED BY STRUCTURAL MODIFICATION

ABSENCE OF GOOD AND

PRESENCE OF BAD GENERALLY GO HAND IN HAND FOR EXAMPLE, THE CHILD WHO WAS RARELY PRAISED WAS PROBABLY ALSO OFTEN CRITICIZED THE CHILD WHO WAS NOT ADMIRED WAS PROBABLY ALSO OFTEN DEVALUED

DEPRIVATION / NEGLECT (DEFICIENCY) AND TRAUMA / ABUSE (TOXICITY) DEMONSTRATE THE SAME YIN AND YANG COMPLEMENTARITY THAT CHARACTERIZES DEFENSE AND ADAPTATION

Module 18

POSITIVE TRANSFERENCE DISRUPTED vs.

NEGATIVE TRANSFERENCE

IN SUM

DISPLACEMENT OF NEED “TO FIND NEW GOOD” GIVES RISE TO ILLUSION AND POSITIVE TRANSFERENCE MODEL 2

PROJECTION OF NEED “TO REFIND OLD BAD” GIVES RISE TO DISTORTION AND NEGATIVE TRANSFERENCE MODEL 3

MODEL 3 WHEN THE PATIENT IS SIMPLY IMAGINING THAT THE THERAPIST EITHER IS OR MIGHT BECOME THE OLD BAD PARENT,

WE SPEAK OF PROJECTION, DISTORTION, AND NEGATIVE TRANSFERENCE BUT WHEN THE THERAPIST IS IMPACTED BY THE PATIENT’S FORCE FIELD SUCH THAT SHE ACTUALLY BECOMES THE OLD BAD PARENT,

THEN WE SPEAK OF PROJECTIVE IDENTIFICATION, REALITY – BASED PERCEPTION, AND ACTUALIZED NEGATIVE TRANSFERENCE WHEN THIS LATTER SITUATION EMERGES, ITS RESOLUTION WILL BE ONE OF THE MOST CHALLENGING – ALBEIT ULTIMATELY REWARDING – THINGS WE WILL EVER BE CALLED UPON TO FACILITATE

MODEL 2 WHEN THE PATIENT IS SIMPLY IMAGINING THAT THE THERAPIST EITHER IS OR MIGHT BECOME A NEW GOOD PARENT,

WE SPEAK OF DISPLACEMENT, ILLUSION, AND POSITIVE TRANSFERENCE BUT WHEN THE THERAPIST IS IMPACTED BY THE PATIENT’S FORCE FIELD SUCH THAT SHE ACTUALLY BECOMES THE NEW GOOD PARENT,

THEN WE SPEAK OF “DISPLACIVE IDENTIFICATION” (STARK 1999), REALITY – BASED PERCEPTION, AND ACTUALIZED POSITIVE TRANSFERENCE

ACTUALIZED POSITIVE TRANSFERENCE IN THE PSYCHOANALYTIC LITERATURE, THIS LATTER SITUATION TENDS TO BE VIEWED AS A “NO – NO” BECAUSE IT IS THOUGHT TO BE FRAUGHT WITH THE POTENTIAL FOR TOO MUCH GRATIFICATION OF THE PATIENT AND AS BEING THEREFORE PRONE TO ESCALATING OUT OF CONTROL BUT JUST AS WE HAVE ALL HAD THE UNCANNY EXPERIENCE OF BEING DRAWN IN BY THE PATIENT’S FORCE FIELD TO DOING “BAD” THINGS THAT HORRIFY US ONCE WE HAVE BECOME AWARE OF HAVING PARTICIPATED COUNTERTRANSFERENTIALLY IN THE PATIENT’S TRANSFERENTIAL RE – ENACTMENT (PROJECTIVE IDENTIFICATION BECAUSE PROJECTION IS INVOLVED), SO TOO MOST OF US HAVE PROBABLY HAD THE UNCANNY EXPERIENCE OF FINDING OURSELVES ABLE TO BE MORE ARTICULATE, MORE LOVING, AND WISER THAN WE COULD EVER HAVE IMAGINED POSSIBLE, IN WHICH CASE WE MIGHT WELL BE RESPONDING TO THE FORCE FIELD CREATED BY A PATIENT DESPERATELY INTENT UPON FINDING A NEW GOOD PARENT AND SO WE ARE NOW UNCONSCIOUSLY “IN COLLUSION WITH HER ILLUSION” THAT WE WILL INDEED BE ABLE TO MAKE UP THE DIFFERENCE TO HER (“DISPLACIVE IDENTIFICATION” BECAUSE DISPLACEMENT IS INVOLVED) (STARK 1994)

AS WITH WORKING THROUGH PROJECTIVE IDENTIFICATION, SO TOO WORKING THROUGH DISPLACIVE IDENTIFICATION CAN BE ONE OF THE MOST POWERFULLY EFFECTIVE EVEN AS IT IS CHALLENGING

TOOLS THAT WE HAVE IN OUR ARMAMENTARIUM NOTE THAT WHEREAS PROJECTIVE IDENTIFICATION FALLS SQUARELY IN THE DOMAIN OF MODEL 3, DISPLACIVE IDENTIFICATION HAS ELEMENTS OF BOTH MODEL 2 BECAUSE IT IS A STORY ABOUT NEW GOOD

AND MODEL 3 BECAUSE IT INVOLVES MUTUALITY OF IMPACT AND TRANSFERENCE / COUNTERTRANSFERENCE ENACTMENT

MODEL 2

ABSENCE OF GOOD WILL REQUIRE “ADDITION” STRUCTURAL GROWTH WHEREAS MODEL 3

PRESENCE OF BAD WILL REQUIRE “SUBTRACTION” STRUCTURAL CHANGE / MODIFICATION AS NOTED EARLIER

TO CORRECT FOR DEFICIENCY REPLENISH THE RESERVES BY ADDING NEW GOOD TO CORRECT FOR TOXICITY LIGHTEN THE LOAD BY CHANGING OLD BAD

MODEL 2

WORKING THROUGH DISRUPTED POSITIVE TRANSFERENCE WORKING THROUGH THE STRESSFUL EXPERIENCE OF GOOD – BECOME – BAD THE EXPERIENCE OF PERFECTION FOLLOWED BY EMPATHIC FAILURE THE EXPERIENCE OF ILLUSION FOLLOWED BY DISILLUSIONMENT

INEVITABLY THIS DYNAMIC WILL HAPPEN REPEATEDLY THE NET RESULT OF WHICH WILL BE GRADUAL ACCRETION OF PSYCHIC STRUCTURE, CONSOLIDATION OF THE SELF, AND TAMING OF THE NEED FOR THE OBJECT TO BE SOMETHING IT IS NOT

A STORY ABOUT CONFRONTING AND GRIEVING HEARTBREAK AND EVOLVING ULTIMATELY TO A PLACE OF SERENE – ALBEIT SOBER – ACCEPTANCE

MODEL 3

WORKING THROUGH NEGATIVE TRANSFERENCE WORKING THROUGH THE STRESSFUL EXPERIENCE OF BAD – BECOME – GOOD

TWO PHASES OF A PROJECTIVE IDENTIFICATION THE INDUCTION PHASE WILL BE INITIATED WHEN A PATIENT UNDER THE SWAY OF HER REPETITION COMPULSION

DRAWS THE THERAPIST IN TO PARTICIPATING AS THE OLD BAD OBJECT

THE RESOLUTION PHASE WILL BE USHERED IN ONCE THE BAD THERAPIST BECOMES ABLE TO PROVIDE CONTAINMENT BY RELENTING, STEPPING BACK, RECOVERING HER PERSPECTIVE, AND TAKING OWNERSHIP OF THE PART SHE HAS BEEN PLAYING IN THE DRAMA BEING MUTUALLY ENACTED BETWEEN THEM

MODEL 3

WORKING THROUGH NEGATIVE TRANSFERENCE BY NEGOTIATING THE VICISSITUDES THAT WILL INEVITABLY ARISE AT THE INTIMATE EDGE AND EVOLVING ULTIMATELY TO A PLACE OF ACCOUNTABILITY AND HEALTHY, AUTHENTIC RELATEDNESS THE NET RESULT OF WHICH WILL BE

RELATIONAL DETOXIFICATION OF TOXIC EXPECTATION

Module 19

SYMBOLIC CORRECTIVE FOR

EARLY – ON DEPRIVATION AND NEGLECT

WHEREAS MODEL 1 IS ABOUT CONFLICT THAT MUST ULTIMATELY BE RESOLVED CONFLICT THAT ARISES IN THE CONTEXT OF AN ID THAT NEEDS TO BE TAMED AND AN EGO THAT NEEDS TO BE STRENGTHENED

MODEL 2 IS ABOUT DEFICIT THAT MUST ULTIMATELY BE CORRECTED FOR DEFICIT THAT ARISES IN THE CONTEXT OF FAILURE IN THE EARLY – ON ENVIRONMENTAL PROVISION

MODEL 2 IS ULTIMATELY ABOUT PROVISION OF CORRECTIVE EXPERIENCE RESONATING EMPATHICALLY WITH THE PATIENT’S AFFECTIVE (“FELT”) EXPERIENCE CONFRONTING THE PATIENT WITH DISILLUSIONING REALITIES FACILITATING ACCESS TO HER UNDERLYING GRIEF TRANSMUTING (STRUCTURE – BUILDING) INTERNALIZATIONS FILLING IN STRUCTURAL DEFICIT DEVELOPING THE CAPACITY TO BE A GOOD PARENT UNTO HERSELF CONSOLIDATING A MORE COHESIVE SELF EVOLVING TO A PLACE OF SERENE ACCEPTANCE AND INNER CALM

IN ESSENCE

MODEL 2 POSITS RESTITUTIVE PROVISION AS THE PRIMARY THERAPEUTIC AGENT MORE ACCURATELY, WORKING THROUGH FAILURES IN THE THERAPIST’S RESTITUTIVE PROVISION

THE ESSENCE OF WHAT IS HEALING IS NO LONGER THOUGHT TO BE SIMPLY “THE TRUTH” (MODEL 1) BUT RATHER “MAKING GOOD A DEFICIENCY” (MODEL 2) THE LIBIDINAL AND AGGRESSIVE DRIVES NOW TAKING A BACK SEAT TO MORE RELATIONAL NEEDS FOR EXAMPLE, THE NEED FOR EMPATHIC RECOGNITION, THE NEED FOR VALIDATION, THE NEED TO BE ADMIRED, THE NEED FOR SOOTHING, AND THE NEED TO BE HELD

THE MODEL 2 THERAPIST IS THOUGHT TO SERVE NO LONGER AS A DRIVE OBJECT BUT RATHER EITHER AS AN EMPATHIC SELFOBJECT USED TO COMPLETE THE SELF BY PERFORMING THOSE FUNCTIONS THAT THE PATIENT IS UNABLE TO PERFORM ON HER OWN

OR A GOOD OBJECT / A GOOD MOTHER OPERATING IN LOCO PARENTIS

THIS CORRECTIVE – PROVISION MODEL FOCUSES ON THE PATIENT’S AFFECTIVE EXPERIENCE HER FELT EXPERIENCE / WHAT IS EXPERIENCE – NEAR ESPECIALLY, THE PAIN OF HER GRIEF THE PAIN OF HER DISAPPOINTMENT / THE PAIN OF HER DISILLUSIONMENT

IN ESSENCE, THE MODEL 2 THERAPIST IS EVER EMPATHICALLY ATTUNED TO THE “POINT OF EMOTIONAL URGENCY” IN THE PATIENT (MODELL 1996)

IT IS FOR THE MODEL 2 THERAPIST TO FOCUS ON UNDERSTANDING EXCLUSIVELY FROM THE PATIENT’S PERSPECTIVE AND WHEN THE THERAPIST’S SUBJECTIVITY INTERFERES WITH HER ABILITY TO IMMERSE HERSELF EMPATHICALLY IN THE PATIENT’S SUBJECTIVE EXPERIENCE, IT IS PEJORATIVELY REFERRED TO AS COUNTERTRANSFERENCE AND IS NOT THOUGHT TO ADVANCE THE THERAPEUTIC ENDEAVOR

EVELYNE SCHWABER’S 1992 ARTICLE ENTITLED “COUNTERTRANSFERENCE: THE ANALYST’S RETREAT FROM THE PATIENT’S VANTAGE POINT” SPEAKS TO HOW COUNTERTRANSFERENCE IS CONCEPTUALIZED IN MODEL 2 IN MARKED CONTRAST TO ITS CRITICALLY INFORMATIVE ROLE IN MODEL 3

THE MODEL 2 THERAPIST MATTERS – BUT ONLY TO THE EXTENT THAT SHE CAN PROVIDE FOR THE PATIENT AND NOT BECAUSE OF WHO SHE IS …

RATHER, THE MODEL 2 THERAPIST IS EXPECTED TO FUNCTION AS A SELFOBJECT THAT PROVIDES EITHER MIRRORING CONFIRMATION OF THE PATIENT’S GRANDIOSE SELF OR AN OPPORTUNITY FOR THE PATIENT TO FUSE IN FANTASY WITH AN IDEALIZED PARENT IMAGO, THEREBY ENABLING THE PATIENT TO PARTAKE OF THE THERAPIST’S IMAGINED PERFECTION MORE GENERALLY, THE MODEL 2 SELFOBJECT THERAPIST OFFERS THE HOLDING, THE BEING MET, AND THE VALIDATION THAT WERE NOT PROVIDED CONSISTENTLY AND RELIABLY BY THE PARENT DURING THE CHILD’S FORMATIVE YEARS

THIS REPARATION FUNCTIONS AS A SYMBOLIC CORRECTIVE FOR THE EARLY – ON DEPRIVATION AND NEGLECT

IT IS THEN IN THE CONTEXT OF THIS NEW RELATIONSHIP THAT THERE WILL BE OPPORTUNITY FOR REPARATION

A “NEW BEGINNING” (BALINT 1968)

AS PREVIOUSLY NOTED

ALTHOUGH SOME MODEL 2 THEORISTS BELIEVE THAT IT IS THE EXPERIENCE OF GRATIFICATION ITSELF THAT IS COMPENSATORY AND ULTIMATELY HEALING, MOST BELIEVE THAT IT IS THE OPTIMAL STRESS CREATED BY THE EXPERIENCE OF FRUSTRATION AGAINST A BACKDROP OF GRATIFICATION FRUSTRATION (DISILLUSIONMENT) PROPERLY GRIEVED THAT IS,

OPTIMAL DISILLUSIONMENT

THAT WILL MOST EFFECTIVELY PROMOTE STRUCTURAL GROWTH AND DEVELOPMENT OF CAPACITY

AGAIN

IF THERE IS NO THWARTING OF DESIRE BY THE THERAPIST, THEN THERE WILL BE NOTHING THAT NEEDS TO BE MASTERED AND THEREFORE NO IMPETUS FOR ADAPTIVE TRANSMUTING INTERNALIZATION AND ACCRETION OF SELF STRUCTURE AND THERE WILL BE NO OPPORTUNITY FOR THE PATIENT, BY WAY OF GRIEVING, TO MAKE HER PEACE WITH THE REALITY THAT SHE WILL NEVER BE ABLE TO HAVE ALL THAT SHE SHOULD HAVE HAD AS A CHILD AND FOR WHICH SHE HAS SPENT A LIFETIME SEARCHING

Module 20

GRIEVING, RELENTING, AND

FORGIVENESS

MODEL 2 WITHIN THE CONTEXT OF SAFETY PROVIDED BY THE RELATIONSHIP WITH HER THERAPIST, THE PATIENT WILL BE GIVEN AN OPPORTUNITY TO GRIEVE THE EARLY – ON PARENTAL FAILURES IN ESSENCE

BY VIRTUE OF THE PATIENT’S TRANSFERENCE TO THE THERAPIST WHEREBY THE PRESENT IS IMBUED WITH THE PRIMAL SIGNIFICANCE OF THE PAST,

MASTERY IN THE HERE – AND – NOW OF NONTRAUMATIC (OPTIMALLY DISILLUSIONING) EXPERIENCES AT THE HANDS OF THE THERAPIST WILL BE TANTAMOUNT TO MASTERY IN THE THERE – AND – THEN OF TRAUMATIC EXPERIENCES SUSTAINED AT THE HANDS OF THE INFANTILE OBJECT

MODEL 2 BUT IN ADDITION TO THIS DIRECT BENEFIT OF WORKING THROUGH TRANSFERENTIAL RUPTURES THEREBY ENABLING EXTRICATION FROM THE BONDS OF INFANTILE ATTACHMENTS,

MASTERY IN THE HERE – AND – NOW OF OPTIMALLY STRESSFUL EXPERIENCES IN RELATION TO THE THERAPIST WILL HELP TO RESTORE THE PATIENT’S RESILIENCE, SUCH THAT SHE WILL BECOME EVER BETTER EQUIPPED TO PROCESS AND INTEGRATE THE IMPACT OF THE MULTITUDE OF DISAPPOINTMENTS, FRUSTRATIONS, AND LOSSES WITH WHICH SHE WILL CONTINUE TO BE CONFRONTED AS SHE MOVES FORWARD BOTH IN THE THERAPY AND, MORE GENERALLY, IN HER LIFE IN ESSENCE, WITH EVERY SUCCESSIVE AND SUCCESSFUL NEGOTIATION OF FIRST RUPTURE AND THEN REPAIR, THE PATIENT WILL EVOLVE TO EVER – HIGHER LEVELS OF FUNCTIONALITY AND ADAPTIVE CAPACITY, THEREBY PROGRESSIVELY INCREASING HER ABILITY TO COPE WITH STRESS AN IMPORTANT HALLMARK OF MENTAL (AND PHYSICAL) HEALTH

ULTIMATELY

THE THERAPEUTIC ACTION IN MODEL 2

INVOLVES THE PATIENT’S GRIEVING FEELING TO THE DEPTHS OF HER SOUL ALL THE ANGUISH, ANGER, FRUSTRATION, DESPAIR, HEARTBREAK, SADNESS, LONELINESS, AND REGRET THAT COME WITH CONFRONTING CERTAIN INTOLERABLY DISILLUSIONING REALITIES ABOUT HER OBJECTS

GRIEVING GRIEVING IS A PROTRACTED PROCESS THAT TRANSFORMS THE PATIENT’S REFUSAL TO CONFRONT THE PAIN OF HER GRIEF ABOUT THE OBJECT’S LIMITATIONS, SEPARATENESS, AND IMMUTABILITY INTO THE CAPACITY TO TOLERATE THOSE INESCAPABLE REALITIES IN THE CONTEXT OF THE TREATMENT, IT INVOLVES

WORKING THROUGH OPTIMAL DISILLUSIONMENT THAT IS, DISRUPTED POSITIVE TRANSFERENCE

BY CONFRONTING THE PAIN OF HER GRIEF, ADAPTIVELY INTERNALIZING THE GOOD THAT HAD BEEN THERE PRIOR TO THE DISRUPTION IF YOU CANNOT ALWAYS COUNT ON EXTERNAL PROVISION, BEST THAT YOU INTERNALIZE WHATEVER GOOD YOU CAN SO THAT IT WILL ALWAYS BE THERE FOR YOU

AND ARRIVING ULTIMATELY AT A PLACE OF SERENE ACCEPTANCE, FORGIVENESS, AND INNER PEACE

GRIEVING ONLY MORE RECENTLY HAVE I COME TO APPRECIATE THAT GENUINE GRIEVING REQUIRES OF US THAT, AT LEAST FOR PERIODS OF TIME, WE BE FULLY PRESENT WITH THE ANGUISH OF OUR GRIEF, THE PAIN OF OUR REGRET, AND THE INTENSITY OF THE RAGE WE WILL EXPERIENCE WHEN WE ARE CONFRONTED WITH SOBERING AND SHOCKING REALITIES ABOUT OURSELVES, OUR RELATIONSHIPS, AND OUR WORLD WE MUST NOT ABSENT OURSELVES FROM OUR GRIEF; WE MUST ENTER INTO AND EMBRACE IT, WITHOUT TURNING AWAY WE CANNOT EFFECTIVELY GRIEVE WHEN WE ARE DISSOCIATED, MISSING IN ACTION, OR FLEEING THE SCENE WE NEED TO BE PRESENT, ENGAGED, IN THE MOMENT, MINDFUL OF ALL THAT IS GOING ON INSIDE OF US, GROUNDED, FOCUSED, AND IN THE HERE – AND – NOW IF, INSTEAD, WE ARE IN DENIAL, UNWILLING TO CONFRONT, CLOSED, SHUT DOWN, NUMB, RETREATING, REFUSING TO FEEL, PROTESTING, OR REFUSING TO ACCEPT, THEN NO REAL GRIEVING CAN BE DONE

GRIEVING GENUINE GRIEVING – USUALLY ACCOMPLISHED ONLY INCREMENTALLY AND OVER TIME – IS THEREFORE AN ONGOING TORTUROUS AND TORTUOUS PROCESS OF ALTERNATELY FALLING INTO THE DEPTHS OF DEVASTATION AND HEARTBREAK AND THEN RAGING AGAINST THE WORLD AND RAILING AGAINST OUR FATE BUT ULTIMATELY IT INVOLVES FORGIVING, RELENTING, SURRENDERING, RELINQUISHING, SEPARATING, AND MOVING ON IT IS WHAT IT IS; IT WAS WHAT IT WAS; AND, AT THE END OF THE DAY, AS THE SERENITY PRAYER REMINDS US, WE MUST ACCEPT THE THINGS THAT WE CANNOT CHANGE, MUST HAVE THE COURAGE TO CHANGE THE THINGS THAT WE CAN, AND MUST HAVE THE WISDOM TO KNOW THE DIFFERENCE (SIFTON 2005)

ALL CHANGE, OF COURSE, INVOLVES LOSS AND A LETTING GO AS WE GRIEVE

GRIEVING ACCORDING TO ELISABETH KUBLER – ROSS (2014), WHEN WE ARE DEALING WITH DEATH OR SOME OTHER CATASTROPHIC LOSS, WE MOVE THROUGH FIVE DISTINCT STAGES OF GRIEF – FIRST WE GO INTO DENIAL BECAUSE THE LOSS IS SO UNTHINKABLE THAT WE CANNOT IMAGINE IT IS TRUE – THEN WE BECOME ANGRY WITH EVERYONE, ANGRY WITH SURVIVORS, ANGRY WITH OURSELVES – AND THEN WE BARGAIN – WE BEG, WE PLEAD, AND WE PROMISE TO RELINQUISH EVERYTHING WE HAVE – WE OFFER UP OUR SOULS IN EXCHANGE FOR JUST ONE MORE DAY – BUT WHEN WE HAVE EXHAUSTED OURSELVES FROM THE EFFORT OF BEING ANGRY AND THE BARGAINING HAS FAILED, WE FALL INTO DEPRESSION, DESPAIR, AND A SENSE OF HELPLESS DEFEAT – UNTIL, EVENTUALLY, WE HAVE TO ACCEPT THAT WE HAVE DONE EVERYTHING THAT WE COULD POSSIBLY HAVE DONE – BUT TO NO AVAIL – AND WE FINALLY SURRENDER – WE LET GO AND MOVE, AT LAST, INTO SOBER ACCEPTANCE OF THE HEARTBREAKING REALITY

“GRIEF IS NATURE’S WAY OF HEALING A BROKEN HEART.” (BECKMAN 1990)

“WHEN A DEEP INJURY IS DONE US, WE NEVER RECOVER UNTIL WE FORGIVE.” (PATON 2003) ALTHOUGH IT MIGHT NOT BE ABSOLUTELY NECESSARY, FORGIVENESS DOES PROBABLY ACCELERATE THE RECOVERY PROCESS CONSIDERABLY

WHAT DOESN’T BEND, ULTIMATELY BREAKS

Module 21

RELENTLESS HOPE AND

THE ILLUSION OF OMNIPOTENT CONTROL

RELENTLESS HOPE PATIENTS WHO ARE NOT ABLE TO STAY PRESENT WITH THE PAIN OF THEIR GRIEF AND THEREFORE ABSENT THEMSELVES FROM THAT PAIN WHO ARE NOT ABLE TO BE MINDFUL OR IN THE MOMENT AND INSTEAD HAVE THE NEED TO DISSOCIATE

MAY NOT BE ABLE EFFECTIVELY TO GRIEVE THEIR LOSSES INSTEAD THEY MAY FIND THEMSELVES CLINGING TENACIOUSLY TO WHAT I (AS NOTED EARLIER) DESCRIBE AS RELENTLESS HOPE (STARK 1994)

THE HOPE A DEFENSE ULTIMATELY AGAINST GRIEVING

RELENTLESS HOPE A PATIENT’S REFUSAL TO DEAL WITH THE PAIN OF HER GRIEF ABOUT THE OBJECT OF HER DESIRE WILL FUEL THE RELENTLESSNESS WITH WHICH SHE PURSUES IT BOTH THE RELENTLESSNESS OF HER HOPE THAT SHE MIGHT YET BE ABLE TO MAKE THE OBJECT OVER INTO WHAT SHE WOULD WANT IT TO BE AND THE RELENTLESSNESS OF THE OUTRAGE SHE EXPERIENCES IN THOSE MOMENTS OF DAWNING RECOGNITION THAT, DESPITE HER BEST EFFORTS AND MOST FERVENT DESIRE, SHE MIGHT NEVER BE ABLE TO MAKE THAT ACTUALLY HAPPEN

RELENTLESS HOPE BUT, EVEN MORE FUNDAMENTALLY, WHAT FUELS THE RELENTLESSNESS OF THE PATIENT’S PURSUIT IS THE FACT OF THE OBJECT’S EXISTENCE AS SEPARATE FROM HERS, AS OUTSIDE THE SPHERE OF HER OMNIPOTENCE, AND AS THEREFORE UNABLE TO BE EITHER POSSESSED OR CONTROLLED IN TRUTH, IT IS THIS VERY IMMUTABILITY OF THE OBJECT THE FACT THAT IT CANNOT BE FORCED TO CHANGE

THAT PROVIDES THE PROPULSIVE FUEL FOR THE PATIENT’S RELENTLESS PURSUIT

RELENTLESS HOPE EVEN IN THE FACE OF INCONTROVERTIBLE EVIDENCE TO THE CONTRARY, THE PATIENT WILL PURSUE THE OBJECT OF HER DESIRE WITH A VENGEANCE, THE INTENSITY OF HER ENTITLED PURSUIT FUELED BY HER CONVICTION THAT THE OBJECT COULD GIVE IT WHERE THE OBJECT BUT WILLING

SHOULD GIVE IT BECAUSE THAT IS HER DUE

AND WOULD GIVE IT WERE SHE BUT ABLE TO GET IT RIGHT

THE FACT THAT THE PATIENT CLINGS SO TENACIOUSLY TO HER BELIEF THAT THE OBJECT WOULD GIVE IT WERE SHE, THE PATIENT, BUT ABLE TO GET IT RIGHT SPEAKS TO THE PATIENT’S DEFENSIVE NEED TO SEE HERSELF AS HAVING THE POWER TO MAKE THINGS CHANGE, AS HAVING THE LOCUS OF CONTROL IN OTHER WORDS

IT SPEAKS TO THE PATIENT’S ILLUSIONS OF GRANDIOSE OMNIPOTENCE

HAD THE PATIENT, AS AN INFANT, HAD THE EXPERIENCE AT LEAST FOR A WHILE

OF A “GOOD ENOUGH MOTHER” WHO WAS ABLE TO “MEET THE OMNIPOTENCE OF HER INFANT” BY RECOGNIZING AND RESPONDING TO THE INFANT’S EVERY NEED, THEN THE PATIENT, PROPELLED BY HER “INBORN MATURATIONAL THRUST,” WOULD HAVE BEEN ABLE GRADUALLY TO “ABROGATE HER NEED FOR OMNIPOTENT CONTROL OF HER OBJECTS” (WINNICOTT 1965) BUT WHEN THE PATIENT, AS AN INFANT, HAS HAD NO SUCH EXPERIENCE, THEN HER ILLUSIONS OF GRANDIOSE OMNIPOTENCE WILL HAVE BECOME DEFENSIVELY REINFORCED OVER TIME, MANIFESTING ULTIMATELY AS A RELENTLESS PURSUIT OF THE UNATTAINABLE THIS PURSUIT FUELED BY HER WISHFUL FANTASY THAT SURELY SHE SHOULD BE ABLE TO MAKE THE OBJECTS OF HER DESIRE RELENT

RELENTLESS HOPE IN THE POIGNANT WORDS OF ELVIN SEMRAD (2003)

“PRETENDING THAT IT CAN BE WHEN IT CAN’T IS HOW PEOPLE BREAK THEIR HEARTS.”

Module 22

RELATIONAL vs. INTERNAL SADOMASOCHISTIC PSYCHODYNAMICS

THE PATIENT’S RELENTLESS PURSUIT HAS BOTH MASOCHISTIC AND SADISTIC COMPONENTS HER RELENTLESS HOPE WHICH FUELS HER MASOCHISM

IS THE STANCE TO WHICH SHE DESPERATELY CLINGS IN ORDER TO AVOID CONFRONTING CERTAIN INTOLERABLY PAINFUL REALITIES ABOUT THE OBJECT AND ITS SEPARATENESS HER RELENTLESS OUTRAGE WHICH FUELS HER SADISM

IS THE STANCE TO WHICH SHE RESORTS IN THOSE MOMENTS OF DAWNING RECOGNITION THAT THE OBJECT IS SEPARATE AND UNYIELDING

I DO NOT LIMIT SADOMASOCHISM TO THE SEXUAL ARENA RATHER, I CONCEIVE OF IT AS A DYSFUNCTIONAL RELATIONAL DYNAMIC THAT GETS PLAYED OUT TO A GREATER OR LESSER EXTENT

IN MANY OF A PERSON’S RELATIONSHIPS ESPECIALLY IF THAT PERSON HAS NOT YET COME TO TERMS WITH THE REALITY THAT THE WORLD WILL NEVER BE ALL THAT SHE WOULD HAVE WANTED IT TO BE

MASOCHISM AND SADISM ALWAYS GO HAND IN HAND IN OTHER WORDS

THE MASOCHISTIC DEFENSE OF RELENTLESS HOPE AND THE SADISTIC DEFENSE OF RELENTLESS OUTRAGE ARE FLIP SIDES OF THE SAME COIN THEY ARE BOTH DEFENSES AND SPEAK TO THE PATIENT’S REFUSAL TO CONFRONT THE PAIN OF HER GRIEF ABOUT THE OBJECT’S LIMITATIONS, SEPARATENESS, AND IMMUTABILITY IN ESSENCE

THEY SPEAK TO THE PATIENT’S REFUSAL TO CONFRONT THE PAIN OF HER GRIEF ABOUT THE OBJECT’S REFUSAL TO BE POSSESSED AND CONTROLLED

MASOCHISM IS A STORY ABOUT THE PATIENT’S HOPE HER RELENTLESS HOPE HER HOPING AGAINST HOPE THAT PERHAPS SOMEDAY, SOMEHOW, SOMEWAY, WERE SHE TO BE BUT GOOD ENOUGH, TRY HARD ENOUGH, BE PERSUASIVE ENOUGH, PERSIST LONG ENOUGH, SUFFER DEEPLY ENOUGH, OR BE “MASOCHISTIC” ENOUGH, SHE MIGHT YET BE ABLE TO EXTRACT FROM THE OBJECT SOMETIMES THE PARENT HERSELF SOMETIMES A STAND – IN FOR THE PARENT

THE RECOGNITION AND LOVE DENIED HER AS A CHILD IN OTHER WORDS

SHE MIGHT YET BE ABLE TO COMPEL THE IMMUTABLE OBJECT TO RELENT NOTE THAT THE INVESTMENT IS NOT SO MUCH IN THE SUFFERING PER SE AS IT IS IN THE PASSIONATE HOPE THAT PERHAPS THIS TIME …

SADISM IS A STORY ABOUT THE RELENTLESS PATIENT’S REACTION TO THE LOSS OF HOPE EXPERIENCED IN THOSE MOMENTS OF DAWNING RECOGNITION THAT SHE IS NOT GOING TO GET, AFTER ALL, WHAT SHE HAD SO DESPERATELY WANTED AND FELT SHE NEEDED TO HAVE IN ORDER TO GO ON ORDINARILY A PERSON WHO HAS BEEN TOLD NO MUST CONFRONT THE PAIN OF HER DISAPPOINTMENT AND COME TO TERMS WITH IT THAT IS, SHE MUST GRIEVE

THE PATIENT MUST ULTIMATELY MAKE HER PEACE WITH THE SOBERING REALITY THAT BECAUSE OF EARLY – ON PARENTAL FAILURES IN THE FORM OF BOTH ABSENCE OF GOOD (DEPRIVATION AND NEGLECT) AND PRESENCE OF BAD (TRAUMA AND ABUSE)

SHE NOW HAS PSYCHIC SCARS THAT MAY NEVER ENTIRELY HEAL AND WILL MOST CERTAINLY MAKE HER JOURNEY THROUGH LIFE RATHER MORE DIFFICULT THAN IT MIGHT OTHERWISE HAVE BEEN

BUT A PERSON WHO IS UNABLE TO ADAPT TO THE REALITY THAT HER OBJECTS WILL NEVER BE ALL THAT SHE WOULD HAVE WANTED THEM TO BE MUST DEFEND HERSELF AGAINST THE KNOWLEDGE OF THAT INTOLERABLY PAINFUL REALITY AND SO, INSTEAD OF CONFRONTING THE PAIN OF HER DISAPPOINTMENT, GRIEVING THE LOSS OF HER ILLUSIONS, ADAPTIVELY INTERNALIZING WHATEVER GOOD THERE WAS, AND RELINQUISHING HER PURSUIT, THE RELENTLESS PATIENT DOES SOMETHING ELSE AS THE PATIENT COMES TO UNDERSTAND THAT SHE IS NOT IN FACT GOING TO BE REWARDED FOR HER UNSTINTING EFFORTS, SHE REACTS WITH THE SADISTIC UNLEASHING OF A TORRENT OF ABUSE DIRECTED EITHER TOWARDS HERSELF FOR HAVING FAILED TO GET WHAT SHE HAD SO DESPERATELY WANTED

OR TOWARDS THE DISAPPOINTING OBJECT FOR HAVING FAILED TO PROVIDE IT

MORE ACCURATELY

THE PATIENT MAY ALTERNATE BETWEEN ENRAGED PROTESTS AT HER OWN INADEQUACY AND SCATHING REPROACHES AGAINST THE OBJECT FOR HAVING FRUSTRATED HER DESIRE

SADISM, THEN, IS A STORY ABOUT THE PATIENT’S RELENTLESS OUTRAGE IN THE FACE OF BEING THWARTED AND THEREBY CONFRONTED WITH THE LIMITS OF HER POWER TO FORCE THE OBJECT TO CHANGE IN OTHER WORDS

WHEN THE PATIENT’S NEED TO POSSESS AND CONTROL THE OBJECT IS FRUSTRATED, WHAT COMES TO THE FORE WILL BE THE PATIENT’S NEED TO PUNISH THE OBJECT BY ATTEMPTING TO DESTROY IT

SO IF A PATIENT IN THE MIDDLE OF A THERAPY SESSION SUDDENLY BECOMES ABUSIVE, WHAT QUESTION MIGHT THE THERAPIST THINK TO POSE? IF THE THERAPIST ASKS “HOW DO YOU FEEL THAT I HAVE FAILED YOU?” AT LEAST SHE KNOWS ENOUGH TO ASK THE QUESTION, BUT SHE IS ALSO INDIRECTLY SUGGESTING THAT THE ANSWER WILL BE PRIMARILY A STORY ABOUT THE PATIENT AND THE PATIENT’S PERCEPTION OF HAVING BEEN FAILED

THEREFORE BETTER TO ASK “HOW HAVE I FAILED YOU?” HERE THE THERAPIST IS SIGNALING HER RECOGNITION OF THE FACT THAT SHE HERSELF MIGHT WELL HAVE CONTRIBUTED TO THE PATIENT’S EXPERIENCE OF DISILLUSIONMENT AND HEARTACHE THE THERAPIST MUST HAVE BOTH THE WISDOM TO RECOGNIZE AND THE INTEGRITY TO ACKNOWLEDGE THE PART SHE MIGHT HAVE PLAYED BY FIRST STOKING THE FLAMES OF THE PATIENT’S DESIRE AND THEN DEVASTATING THROUGH HER FAILURE, ULTIMATELY, TO DELIVER

IN ANY EVENT

THE SADOMASOCHISTIC CYCLE IS REPEATED ONCE THE (SEDUCTIVE) OBJECT THROWS THE PATIENT A FEW CRUMBS THE SADOMASOCHIST EVER HUNGRY FOR SUCH MORSELS

WILL BECOME ONCE AGAIN HOOKED AND REVERT TO HER ORIGINAL STANCE OF SUFFERING, SACRIFICE, AND SURRENDER IN A REPEAT ATTEMPT TO GET WHAT SHE SO DESPERATELY WANTS AND FEELS SHE MUST HAVE

RELATIONAL vs. INTERNAL SADOMASOCHISTIC DEFENSES

SADOMASOCHISM CAN BE PLAYED OUT EITHER RELATIONALLY IN THE FORM OF ALTERNATING CYCLES OF RELENTLESS HOPE AND RELENTLESS OUTRAGE

OR INTERNALLY IN THE FORM OF ALTERNATING CYCLES OF SELF – INDULGENCE AND SELF – DESTRUCTIVENESS IN OTHER WORDS

THE SADOMASOCHISTIC PATIENT WHO HAS A LIBIDINAL (RELENTLESSLY HOPEFUL) AND AN AGGRESSIVE (RELENTLESSLY OUTRAGED) ATTACHMENT TO THE BAD OBJECT MAY WELL ALSO HAVE A LIBIDINAL (RELENTLESSLY SELF – INDULGENT) AND AN AGGRESSIVE (RELENTLESSLY SELF – DESTRUCTIVE) ATTACHMENT TO THE BAD SELF

FOR EXAMPLE, CONSIDER A PATIENT WITH A SEEMINGLY INTRACTABLE EATING DISORDER, ONE THAT COMPELS HER SOMETIMES TO BINGE THEREBY AFFORDING LIBIDINAL RELEASE

AND SOMETIMES TO FAST THEREBY AFFORDING AGGRESSIVE RELEASE THE VICIOUSLY SELF – SABOTAGING CYCLE MIGHT GO AS FOLLOWS –

A CALORIE – RESTRICTING PATIENT, FEELING DEPRIVED, BECOMES RESENTFUL AND THEN FEELS ENTITLED TO GRATIFY HERSELF BY INDULGING IN COMPULSIVE EATING, WHICH THEN MAKES HER FEEL GUILTY AND PROMPTS HER TO PUNISH HERSELF BY SEVERELY RESTRICTING HER CALORIC INTAKE (ONCE AGAIN), WHICH THEN MAKES HER FEEL DEPRIVED, ANGRY, AND ENTITLED TO INDULGE IN YET ANOTHER EATING BINGE, AND SO ON AND SO FORTH CYCLES OF DEPRIVATION, SELF – INDULGENCE, GUILT, SELF – DESTRUCTIVENESS AND SO IT IS THAT WE SPEAK OF

THE MASOCHISTIC DEFENSE OF SELF – INDULGENCE AND THE SADISTIC DEFENSE OF SELF – DESTRUCTIVENESS IN RELATION TO THE “BAD SELF” JUST AS WE SPEAK OF

THE MASOCHISTIC DEFENSE OF RELENTLESS HOPE AND THE SADISTIC DEFENSE OF RELENTLESS OUTRAGE IN RELATION TO THE “BAD OBJECT”

ACCEPTING THE REALITY OF THE OBJECT AS SEPARATE

IF THE PATIENT IS EVER TO RELINQUISH HER COMPULSIVE RE – ENACTMENTS, HER RELENTLESS PURSUITS, HER INFANTILE NEED TO POSSESS AND CONTROL, AND HER SELF – INDULGENT / SELF – DESTRUCTIVE BEHAVIORS, THE REALITY OF THE OBJECT AS SEPARATE FROM THE SELF AND AS HAVING ITS OWN CENTER OF INITIATIVE MUST ULTIMATELY BE CONFRONTED AND GRIEVED BUT IF THE PATIENT IS UNABLE TO MAKE HER PEACE WITH THE REALITY THAT HER OBJECTS ARE SEPARATE AND THEREFORE IMMUTABLE, THEN SHE WILL BE CONSIGNING HERSELF TO A LIFETIME OF CHRONIC FRUSTRATION, UNRELENTING HEARTBREAK, IMPOTENT RAGE, PROFOUND DESPAIR, AND TORMENTING FEELINGS OF HELPLESSNESS AND POWERLESSNESS EVERY TIME SHE IS CONFRONTED WITH THE INESCAPABLE REALITY THAT HER OBJECTS CANNOT BE POSSESSED, CONTROLLED, OR MADE OVER INTO WHOM SHE WOULD HAVE WANTED THEM TO BE

THE SCHIZOID DEFENSE OF RELENTLESS DESPAIR AND PROFOUND HOPELESSNESS (STARK 2015) BECAUSE OF INTOLERABLY PAINFUL EARLY – ON DISAPPOINTMENTS AND HEARTACHE, THE INNERMOST SELF OF THE SCHIZOID PATIENT HAS SECRETLY WITHDRAWN THE NEED IS TO PROTECT THE INTEGRITY OF A PRECARIOUSLY ESTABLISHED SELF FROM BEING SHATTERED (OR “FRACTURED”) BY A HEARTBREAKING RESPONSE FROM THE OBJECT (MODELL 1996) THUS THE PSYCHIC RETREAT (SCHIZOID WITHDRAWAL) AND DENIAL OF OBJECT NEED SUPPORTED BY ILLUSIONS OF GRANDIOSE SELF – SUFFICIENCY ON THE ONE HAND

THE SCHIZOID PATIENT YEARNS TO BE IN RELATIONSHIP BUT FEARS CATASTROPHIC REJECTION ON THE OTHER HAND

LACK OF CONNECTION IS ACCOMPANIED BY FEAR OF EGO DISSOLUTION AND FRAGMENTATION AND TERRIFYING AWARENESS OF HER ULTIMATE SEPARATENESS AND ALONENESS

TO REVIEW

THE SCHIZOID DEFENSE OF RELENTLESS DESPAIR AND PROFOUND HOPELESSNESS THE DILEMMA OF THE SCHIZOID IS THAT SHE HAS AN UNDERLYING INTENSE LONGING TO BE CLOSE BUT A TERROR OF BEING FOUND AND SO IT IS THAT SHE DETACHES HERSELF COMPLETELY FROM OBJECTS AND RENOUNCES ALL HOPE THE GOAL IS TO CANCEL RELATIONSHIPS, TO MAKE NO DEMANDS, AND TO WANT NO ONE

“HUMANKIND CANNOT BEAR VERY MUCH REALITY.” (ELIOT 1943)

Module 23

DISILLUSIONMENT STATEMENTS AND

ADAPTIVE TRANSMUTING INTERNALIZATION

SO HOW DO WE HELP OUR PATIENTS GRIEVE? MODEL 1

CONFLICT STATEMENTS STRIVE TO HIGHLIGHT THE PATIENT’S INTERNAL CONFLICT BY FIRST SPEAKING TO THE PATIENT’S ADAPTIVE CAPACITY TO ACKNOWLEDGE CERTAIN PAINFUL TRUTHS AND THEN RESONATING EMPATHICALLY WITH THE PATIENT’S DEFENSIVE NEED TO PROTEST MODEL 2

DISILLUSIONMENT STATEMENTS STRIVE TO FACILITATE THE PATIENT’S GRIEVING BY FIRST SPEAKING TO THE PATIENT’S ADAPTIVE CAPACITY TO ACKNOWLEDGE CERTAIN PAINFUL TRUTHS AND THEN RESONATING EMPATHICALLY WITH THE PAIN OF THE PATIENT’S GRIEF AS SHE BEGINS TO FACE THOSE TRUTHS BOTH INTERVENTIONS ARE ANXIETY – PROVOKING BUT ULTIMATELY GROWTH – PROMOTING

AWARENESS – PROMOTING INTERVENTION

MODEL 1 CONFLICT STATEMENT (BUT) YOU KNOW THAT ULTIMATELY YOU WILL NEED TO LET JOSE GO BECAUSE HE, LIKE YOUR DAD, REALLY ISN’T AVAILABLE IN THE WAY THAT YOU WOULD HAVE WANTED HIM TO BE; BUT, FOR NOW, ALL YOU CAN THINK ABOUT IS HOW DESPERATELY YOU WANT TO BE WITH HIM. ACCEPTANCE – PROMOTING INTERVENTION

MODEL 2 DISILLUSIONMENT STATEMENT (AND) YOU KNOW THAT ULTIMATELY YOU WILL NEED TO LET JOSE GO BECAUSE HE, LIKE YOUR DAD, REALLY ISN’T AVAILABLE IN THE WAY THAT YOU WOULD HAVE WANTED HIM TO BE; AND IT BREAKS YOUR HEART.

MODEL 1 CONFLICT STATEMENT “YOU KNOW THAT …, BUT YOU (MADE ANXIOUS) FIND YOURSELF THINKING, FEELING, OR DOING IN ORDER NOT TO HAVE TO KNOW …”

AT LEAST ON SOME LEVEL THE PATIENT DOES KNOW “BUT” IS MADE INTOLERABLY ANXIOUS

MODEL 2 DISILLUSIONMENT STATEMENT “YOU KNOW THAT …, AND IT BREAKS YOUR HEART …”

AT LEAST ON SOME LEVEL THE PATIENT DOES KNOW “AND” IS BEGINNING TO CONFRONT IT

THE PATIENT DOES KNOW “AND” IS NOW BETTER ABLE TO TOLERATE THE PAIN OF IT

AND SO THE THERAPIST USES A DISILLUSIONMENT STATEMENT TO HELP THE PATIENT ACCESS HER GRIEF

MORE SPECIFICALLY

MODEL 2 DISILLUSIONMENT STATEMENTS ARE DESIGNED TO FACILITATE THE GRIEVING OF A PATIENT WHO IS BEGINNING TO ACKNOWLEDGE THE PAIN OF HER GRIEF

FIRST THE THERAPIST CHALLENGES BY HIGHLIGHTING THE DISILLUSIONING REALITY THAT THE PATIENT IS GRADUALLY COMING TO RECOGNIZE AND THEN IF THE THERAPIST SENSES THAT THE PATIENT IS READY

SUPPORTS BY RESONATING EMPATHICALLY WITH THE PATIENT’S EXPERIENCE OF HEARTBREAK “YOU KNOW THAT …, AND IT BREAKS YOUR HEART …” THESE STATEMENTS ARE USED IN THOSE MOMENTS WHEN THE PATIENT IS NO LONGER AS DEFENDED AND IS NOW BETTER ABLE TO CONFRONT – AND GRIEVE – THE PAIN OF HER DISAPPOINTMENT

WITH RESPECT TO THE SECOND PART OF A DISILLUSIONMENT STATEMENT

THE MODEL 2 THERAPIST MIGHT OFFER THE HEARTBROKEN PATIENT ANY OF THE FOLLOWING

I WONDER IF IT BREAKS YOUR HEART … IT SOUNDS AS IF IT BREAKS YOUR HEART … IT SEEMS AS IF IT BREAKS YOUR HEART … IT MUST BREAK YOUR HEART … BUT MORE TO THE POINT IS THE FOLLOWING

IT BREAKS YOUR HEART … THERE IS NO NEED FOR THOSE EXTRA WORDS AT THE BEGINNING

WHETHER THE THERAPIST USES A CONFLICT STATEMENT OR A DISILLUSIONMENT STATEMENT OR CONSTRUCTS SOME OTHER INTERVENTION THAT ALTERNATELY INCREASES THE PATIENT’S ANXIETY BY DIRECTING HER ATTENTION TO WHERE SHE WOULD RATHER NOT BE

AND THEN DECREASES HER ANXIETY BY VALIDATING WHERE SHE IS

THE UNDERLYING PRINCIPLE WILL BE THE THERAPEUTIC USE OF STRESS TO PROVOKE RECOVERY

TO FACILITATE THE GRIEVING PROCESS

THE THERAPIST REPEATEDLY DIRECTS THE PATIENT’S ATTENTION BACK AND FORTH

BETWEEN CONFRONTING HER WITH UNCOMFORTABLE REALITIES THAT, AT LEAST ON SOME LEVEL, SHE REALLY DOES KNOW TO BE TRUE

AND THEN RESONATING EMPATHICALLY WITH HOW THE PATIENT IS DEALING WITH THEM IF DEFENSIVELY (BECAUSE THE PAIN IS SIMPLY TOO MUCH), A CONFLICT STATEMENT IF ADAPTIVELY (BECAUSE THE PAIN IS MORE TOLERABLE), A DISILLUSIONMENT STATEMENT

IF THE EXPERIENCE OF DISILLUSIONING HEARTBREAK THE STRESSFUL EXPERIENCE OF GOOD – BECOME – BAD

CAN ULTIMATELY BE ADEQUATELY PROCESSED AND INTEGRATED THAT IS, GRIEVED

THE PATIENT WILL ADAPTIVELY INTERNALIZE THOSE SELFOBJECT FUNCTIONS THAT THE OBJECT HAD BEEN PERFORMING PRIOR TO ITS DISAPPOINTMENT OF HER TRANSMUTING (STRUCTURE – BUILDING) INTERNALIZATIONS

THEREBY FILLING IN DEFICIT AND CONSOLIDATING THE SELF FROM “SOME HOLES” TO “WHOLESOME” THE THERAPEUTIC ACTION IN MODEL 2

THESE STRUCTURE – BUILDING INTERNALIZATIONS WILL ENABLE THE PATIENT TO PRESERVE INTERNALLY A PIECE OF THE ORIGINAL EXPERIENCE OF EXTERNAL GOODNESS (THUS THEIR ADAPTIVE VALUE)

AT THE END OF THE DAY

MODEL 2 IS ABOUT THE PATIENT’S CONFRONTING AND GRIEVING THE REALITY OF THE OBJECT’S LIMITATIONS, SEPARATENESS, AND IMMUTABILITY AND BY WAY OF RELENTING, FORGIVING, INTERNALIZING, SEPARATING, LETTING GO, AND MOVING ON

ARRIVING ULTIMATELY AT A PLACE OF SERENE ACCEPTANCE IN THE PROCESS, ALSO MAKING HER PEACE WITH THE REALITY OF THE LIMITS OF HER POWER TO FORCE THE OBJECT TO CHANGE

MODEL 2 – WORKING THROUGH DISAPPOINTMENT AS THE RELENTLESS PATIENT BEGINS TO GRIEVE AND GRADUALLY TO LET GO OF HER NEED TO POSSESS AND CONTROL THE OBJECT AND, WHEN THWARTED, HER NEED TO ATTEMPT ITS DESTRUCTION THROUGH RETALIATION, SHE WILL SLOWLY BUT SURELY RELINQUISH HER RELENTLESS PURSUIT OF THE UNATTAINABLE IN FAVOR OF REFOCUSING HER ENERGIES ON THE PURSUIT OF MORE APPROPRIATE, AND MORE ATTAINABLE, OBJECTS

THE THERAPEUTIC ACTION IN MODEL 2 IS THEREFORE SEEN AS BEING A STORY ABOUT WORKING THROUGH THE PATIENT’S EXPERIENCE OF BEING DISAPPOINTED THAT IS, OPTIMALLY DISILLUSIONED

AT THE HANDS OF A THERAPIST OFTEN A STAND – IN FOR THE PARENT

WHO TURNS OUT TO BE NOT ALL THAT THE PATIENT WOULD HAVE HOPED SHE COULD BE PROMPTING EVENTUAL RELINQUISHMENT OF THE PATIENT’S RELENTLESS HOPE AND DECATHEXIS OF THE AMBIVALENTLY HELD (AND TORMENTING) OBJECT OF HER DESIRE

ONLY ONCE THE PATIENT HAS BEEN ABLE TO MASTER AND INTEGRATE HER DISSOCIATED GRIEF WILL SHE BE ABLE TO RELINQUISH HER RELENTLESS AND INFANTILE PURSUIT OF THE UNATTAINABLE SHE WILL HAVE TRANSFORMED DYSFUNCTIONAL DEFENSE THE NEED TO HOLD ON

INTO MORE FUNCTIONAL ADAPTATION THE CAPACITY TO LET GO

ONCE SHE HAS GRIEVED AND, IN THE PROCESS, DEVELOPED A MORE REFINED AWARENESS OF THE LIMITATIONS INHERENT IN RELATIONSHIP AND A MORE EVOLVED CAPACITY TO ACCEPT THAT WHICH SHE CANNOT CHANGE

IN SUM

THE THERAPEUTIC ACTION IN MODEL 2 INVOLVES WORKING THROUGH DISRUPTED POSITIVE TRANSFERENCE THAT IS, GRIEVING DISILLUSIONMENT

THE EXPERIENCE OF GOOD – BECOME – BAD

THEREBY TRANSFORMING RELENTLESS HOPE INTO MATURE ACCEPTANCE

I AM HERE REMINDED OF THE NEW YORKER CARTOON IN WHICH A GENTLEMAN, SEATED IN A RESTAURANT NAMED THE DISILLUSIONMENT CAFÉ, IS AWAITING THE ARRIVAL OF HIS ORDER THE WAITER RETURNS TO HIS TABLE AND ANNOUNCES, “YOUR ORDER IS NOT READY, AND NOR WILL IT EVER BE”

Module 24

OBJECTIVE NEUTRALITY vs.

EMPATHIC ATTUNEMENT vs.

AUTHENTIC ENGAGEMENT

REVIEW

WHEREAS THE THERAPEUTIC ACTION IN MODEL 2 INVOLVES WORKING THROUGH

POSITIVE TRANSFERENCE DISRUPTED THE EXPERIENCE OF GOOD – BECOME – BAD DISILLUSIONMENT

THEREBY TRANSFORMING RELENTLESSNESS INTO SERENE ACCEPTANCE THE THERAPEUTIC ACTION IN MODEL 3 INVOLVES WORKING THROUGH

NEGATIVE TRANSFERENCE THE EXPERIENCE OF BAD – BECOME – GOOD DETOXIFICATION

THEREBY TRANSFORMING RE – ENACTMENT INTO ACCOUNTABILITY

MODEL 2 IS ABOUT DISILLUSIONMENT AND STRUCTURAL GROWTH ADDING NEW GOOD TO CORRECT FOR DEFICIENCY

MODEL 3 IS ABOUT DETOXIFICATION AND STRUCTURAL MODIFICATION CHANGING OLD BAD TO CORRECT FOR TOXICITY

MODEL 3 THE INTERSUBJECTIVE PERSPECTIVE OF CONTEMPORARY RELATIONAL THEORY

A 2 – PERSON PSYCHOLOGY FOCUSES ON THERAPISTS AND PATIENTS WHO RELATE TO EACH OTHER AS REAL PEOPLE

BOTH OF WHOM BRING THEIR AUTHENTIC SELVES INTO THE ROOM

MODEL 3 RECIPROCITY MUTUALITY OF INFLUENCE / IMPACT HERE – AND – NOW ENGAGEMENT CO – CREATION OF EXPERIENCE TRANSFERENCE / COUNTERTRANSFERENCE ENTANGLEMENT USE OF THE THERAPIST’S SELF TO FIND, AND BE FOUND BY, THE PATIENT CONTRIBUTIONS OF BOTH PARTICIPANTS TO THE TURBULENCE THAT WILL INEVITABLY ARISE BETWEEN THEM

KOHUT WRITES ABOUT THE “INEVITABLE EMPATHIC FAILURE” (KOHUT 1966)

HOW MIGHT WE UNDERSTAND THE INEVITABILITY OF SUCH FAILURE? IS IT PRIMARILY A STORY ABOUT THE THERAPIST AND HER LACK OF PERFECTION? IS IT PRIMARILY A STORY ABOUT THE PATIENT AND HER EXERTING OF INTERPERSONAL PRESSURE ON THE THERAPIST TO PARTICIPATE AS THE OLD BAD OBJECT? OR

MODEL 2 SELF PSYCHOLOGY CONTENDS THAT THE THERAPIST WILL INEVITABLY FAIL THE PATIENT BECAUSE THE THERAPIST IS NOT PERFECT AND CANNOT BE EXPECTED TO BE PERFECT

MODEL 3 BUT MANY RELATIONAL THEORISTS BELIEVE THAT A THERAPIST’S FAILURES OF HER PATIENT ARE NOT JUST A STORY ABOUT THE THERAPIST AND THE THERAPIST’S LACK OF PERFECTION

BUT ALSO A STORY ABOUT THE PATIENT AND THE PATIENT’S EXERTING OF INTERPERSONAL PRESSURE ON THE THERAPIST TO PARTICIPATE IN WAYS BOTH “FAMILIAL AND THEREFORE FAMILIAR” (MITCHELL 1988)

IN OTHER WORDS

THE CONTEMPORARY RELATIONAL PERSPECTIVE CONCEIVES OF THE THERAPIST’S FAILURES AS SPEAKING TO HER OPENNESS TO BECOMING A PARTICIPANT IN THE PATIENT’S COMPULSIVE AND UNWITTING RE – ENACTMENTS

MORE SPECIFICALLY

RELATIONAL THEORY HAS IT THAT THE THERAPIST’S FAILURES DO NOT SIMPLY HAPPEN IN A VACUUM RATHER, THEY OCCUR IN THE CONTEXT OF AN ONGOING, CONTINUOUSLY EVOLVING RELATIONSHIP BETWEEN TWO REAL PEOPLE AND SPEAK TO THE THERAPIST’S RECEPTIVITY TO THE PATIENT’S UNCONSCIOUS NEED TO BE FAILED IN WAYS SPECIFICALLY DETERMINED BY HER EARLY – ON DEVELOPMENTAL HISTORY (CASEMENT 1992) AND INTERNALLY RECORDED AND STRUCTURALIZED IN THE FORM OF INTERNAL BAD OBJECTS AND DYSFUNCTIONAL RELATIONAL DYNAMICS THE MODEL 3 THERAPIST’S FAILURES OF HER PATIENT ARE THEREFORE THOUGHT TO BE CO – CONSTRUCTED – BOTH A STORY ABOUT THE THERAPIST (AND WHAT SHE GIVES / BRINGS TO THE THERAPEUTIC INTERACTION) AND A STORY ABOUT THE PATIENT (AND WHAT SHE GIVES / BRINGS TO THE THERAPEUTIC INTERACTION)

AS NOTED EARLIER

WHEN THE MODEL 3 RELATIONAL THERAPIST PARTICIPATES AS AN AUTHENTIC SUBJECT, THIS USUALLY BECOMES A STORY ABOUT ALLOWING HERSELF TO BE DRAWN IN TO PARTICIPATING AS THE OLD BAD OBJECT

THE LOCUS OF THE THERAPEUTIC ACTION IN MODEL 3 ALWAYS INVOLVES THIS MUTUALITY OF IMPACT, BOTH THERAPIST AND PATIENT AS AUTHENTIC SUBJECTS

CONTINUOUSLY CHANGING SOMETIMES FOR THE BETTER, SOMETIMES FOR THE WORSE

BY VIRTUE OF BEING IN RELATIONSHIP WITH EACH OTHER THIS IS IN MARKED CONTRAST TO THE EMPATHIC MODEL 2 THERAPIST, WHOSE AUTHENTICITY AND SUBJECTIVITY ARE THOUGHT TO BE IMPEDIMENTS TO HER ABILITY TO BE EVER EMPATHICALLY ATTUNED TO THE PATIENT’S VANTAGE POINT AND ARE THEREFORE TO BE KEPT OUT OF THE ROOM

THE AUTHENTIC ENGAGEMENT OF THE MODEL 3 THERAPIST vs. THE EMPATHIC ATTUNEMENT OF THE MODEL 2 THERAPIST

AS AN AUTHENTIC SUBJECT, THE MODEL 3 THERAPIST REMAINS VERY MUCH CENTERED WITHIN HER OWN EXPERIENCE, ALLOWS THE PATIENT’S EXPERIENCE TO ENTER INTO HER, AND TAKES IT ON “AS” HER OWN THEREBY LETTING HERSELF BE CHANGED BY IT

THE AUTHENTIC ENGAGEMENT OF THE MODEL 3 THERAPIST vs. THE EMPATHIC ATTUNEMENT OF THE MODEL 2 THERAPIST

AS AN EMPATHIC SELFOBJECT, THE MODEL 2 THERAPIST DECENTERS FROM HER OWN EXPERIENCE, JOINS ALONGSIDE THE PATIENT, AND ENTERS INTO THE PATIENT’S EXPERIENCE BUT SHE TAKES IT ON ONLY “AS IF” IT WERE HER OWN BECAUSE IT NEVER ACTUALLY BECOMES HER OWN

TO REVIEW

SO THERE ARE THREE DISTINCTLY DIFFERENT POSITIONS THAT THE THERAPIST WILL ASSUME, MOMENT BY MOMENT, WITH RESPECT TO HOW SHE LISTENS AND HOW SHE THEN REACTS / RESPONDS

THE OBJECTIVE NEUTRALITY OF THE MODEL 1 THERAPIST HEAD

THE EMPATHIC ATTUNEMENT OF THE MODEL 2 THERAPIST HEART

THE AUTHENTIC ENGAGEMENT OF THE MODEL 3 THERAPIST GUT

MORE GENERALLY

HOW THE THERAPIST POSITIONS HERSELF MOMENT BY MOMENT

THE OPTIMAL THERAPEUTIC STANCE WILL BE ONE THAT IS CONTINUOUSLY SHIFTING SOMETIMES SPONTANEOUS AND UNPLANNED, SOMETIMES MORE CONSIDERED AND DELIBERATE SOMETIMES THE THERAPIST WILL FIND HERSELF UNWITTINGLY DRAWN IN TO PARTICIPATING IN A CERTAIN WAY BUT AT OTHER TIMES THE THERAPIST WILL MAKE A MORE CONSCIOUS CHOICE BASED ON WHAT SHE SENSES THE PATIENT MOST NEEDS IN THE MOMENT IN ORDER TO HEAL

Module 25

ENACTMENT AND

THE PATIENT AS INTENTIONED

IN SUM

WHEREAS MODEL 2 CONCEIVES OF THE PATIENT AS HAVING THE NEED TO FIND A NEW GOOD OBJECT, MODEL 3 CONCEIVES OF THE PATIENT AS HAVING THE NEED TO REFIND THE OLD BAD OBJECT (BOLLAS’S “CREATED ENVIRONMENT” 1989)

SO THAT THE PATIENT CAN HAVE AN OPPORTUNITY TO REVISIT THE EARLY – ON TRAUMATIC FAILURE SITUATION AND ACHIEVE MASTERY THIS TIME

REPETITION COMPULSION BOTH UNHEALTHY AND HEALTHY ASPECTS THE UNHEALTHY PIECE HAS TO DO WITH THE PATIENT’S NEED TO HAVE MORE OF SAME NO MATTER HOW PATHOLOGICAL

BECAUSE THAT IS ALL THE PATIENT HAS EVER KNOWN HAVING SOMETHING DIFFERENT WOULD CREATE ANXIETY BECAUSE IT WOULD HIGHLIGHT THE FACT THAT THINGS COULD BE AND COULD THEREFORE HAVE BEEN

DIFFERENT IN ESSENCE, HAVING SOMETHING DIFFERENT WOULD CHALLENGE THE PATIENT’S ATTACHMENT TO THE INFANTILE (PARENTAL) OBJECT

REPETITION COMPULSION

(CONTINUED)

BOTH UNHEALTHY AND HEALTHY ASPECTS

BUT THE HEALTHY PIECE OF THE PATIENT’S NEED TO BE NOW FAILED AS SHE WAS ONCE FAILED HAS TO DO WITH HER NEED TO HAVE THE OPPORTUNITY TO ACHIEVE BELATED MASTERY OF THE EARLY – ON PARENTAL FAILURES THE HOPE BEING THAT PERHAPS THIS TIME THERE WILL BE A DIFFERENT OUTCOME

CLASSICAL PSYCHOANALYSTS SPEAK OF SUPEREGO INTROJECTS FOR EXAMPLE, A CRITICAL SUPEREGO INTROJECT A HARSHLY PUNITIVE SUPEREGO INTROJECT WHERE ONCE THE ABUSIVE PARENT HAD RAILED AGAINST THE CHILD, NOW THAT DYNAMIC GETS PLAYED OUT BETWEEN SUPEREGO AND EGO (WITH THE SUPEREGO NOW RAILING AGAINST THE EGO)

BUT I THINK IT IS MORE CLINICALLY USEFUL TO CONCEIVE OF SUCH PATHOGENIC INTROJECTS AS EXISTING IN PAIRS FOR EXAMPLE, CRITICIZER AND CRITICIZEE / VICTIMIZER AND VICTIM

AND OF THE THERAPEUTIC ACTION AS THEREFORE A STORY ABOUT NEGOTIATING THE TREACHEROUS VICISSITUDES THAT WILL INEVITABLY EMERGE AT THE INTIMATE EDGE OF AUTHENTIC ENGAGEMENT BETWEEN THERAPIST AND PATIENT ONCE A PATIENT DELIVERS HER DYSFUNCTIONAL RELATIONAL DYNAMIC OF HER THERE – AND – THEN INTO THE HERE – AND – NOW OF THE TRANSFERENCE WHERE ONCE THE ABUSIVE PARENT HAD RAILED AGAINST THE CHILD, NOW THAT DYNAMIC GETS PLAYED OUT BETWEEN THERAPIST AND PATIENT (WITH ULTIMATELY BOTH RAILING AGAINST EACH OTHER)

ONCE WE APPRECIATE THAT INTERNAL BAD OBJECTS ALWAYS EXIST IN PAIRS, WE MUST RECOGNIZE THAT THE PATIENT CAN IDENTIFY WITH EITHER POLE OF THE INTROJECTIVE CONSTELLATION AND THEN PROJECT THE OTHER POLE ONTO THE THERAPIST

THE ACTIVE POLE WILL GENERALLY BE THE ROLE OF THE PARENT IN RELATION TO THE CHILD

THE PASSIVE POLE WILL GENERALLY BE THE ROLE OF THE CHILD IN RELATION TO THE PARENT

WHEN THE PATIENT IDENTIFIES WITH THE PASSIVE POLE, PROJECTS THE ACTIVE POLE ONTO THE THERAPIST, AND THEN GETS HER THERAPIST TO DO UNTO HER THE BAD THAT HAD BEEN DONE UNTO HER AS A CHILD, WE SPEAK OF A “DIRECT” NEGATIVE TRANSFERENCE WHEN THE PATIENT IDENTIFIES WITH THE ACTIVE POLE, PROJECTS THE PASSIVE POLE ONTO THE THERAPIST, AND THEN DOES UNTO HER THERAPIST THE BAD THAT HAD BEEN DONE UNTO HER AS A CHILD, WE SPEAK OF AN “INVERTED” NEGATIVE TRANSFERENCE (STARK 1994)

UNLIKE MODEL 2 WHICH PAYS RELATIVELY LITTLE ATTENTION TO THE PATIENT’S PROACTIVITY IN RELATION TO THE THERAPIST MODEL 3 ADDRESSES ITSELF SPECIFICALLY TO THE FORCE FIELD CREATED BY THE PATIENT WHO UNDER THE SWAY OF HER REPETITION COMPULSION

IS THOUGHT TO BE EVER INTENT UPON RECREATING THROUGH PROJECTIVE IDENTIFICATION

THE EARLY – ON TRAUMATIC FAILURE SITUATION BY DRAWING THE THERAPIST IN TO PARTICIPATING AS THE OLD BAD OBJECT WHICH IS WHAT MUST HAPPEN IF THE PATIENT IS EVER TO CONQUER HER INTERNAL DEMONS STRUCTURAL MODIFICATION

IN OTHER WORDS

THE RELATIONAL MODEL CONCEIVES OF THE PATIENT AS AN AGENT, AS PROACTIVE, AS INTENTIONED IN HER ACTIVITIES, AND AS ACCOUNTABLE WHETHER SHE LIKES IT OR NOT THE MODEL 3 THERAPIST THEREFORE ATTENDS CLOSELY TO WHAT THE PATIENT DELIVERS OF HERSELF INTO THE THERAPY RELATIONSHIP AND TO HER OWN COUNTERTRANSFERENTIAL REACTION / RESPONSE TO THE PATIENT’S TRANSFERENTIAL ENACTMENTS

IN FACT

THE PATIENT’S ACTIVITY IN RELATION TO THE THERAPIST IS SEEN AS AN

ENACTMENT THE UNCONSCIOUS INTENT OF WHICH IS TO ENGAGE THE THERAPIST IN SOME FASHION EITHER

BY ELICITING (PROVOKING) FROM THE THERAPIST A “FAMILIAL AND THEREFORE FAMILIAR” REACTION (MITCHELL 1988) OR

BY COMMUNICATING TO THE THERAPIST SOMETHING DEEPLY IMPORTANT AND UNMASTERED ABOUT THE PATIENT’S INTERNAL WORLD

ACTUALLY

THE PATIENT MAY KNOW OF NO OTHER WAY TO GET SOME UNRESOLVED PIECE OF HER SUBJECTIVE EXPERIENCE UNDERSTOOD USUALLY AN UNPROCESSED AND UNINTEGRATED RELATIONAL TRAUMA FROM EARLY – ON

THAN BY UNWITTINGLY ENACTING IT IN THE RELATIONSHIP WITH HER THERAPIST THEREBY CREATING EITHER A DIRECT NEGATIVE TRANSFERENCE OR AN INVERTED NEGATIVE TRANSFERENCE THE COMPLEX VICISSITUDES OF WHICH WILL NEED TO BE NEGOTIATED AT THE INTIMATE EDGE OF AUTHENTIC RELATEDNESS FOR THERE TO BE STRUCTURAL RESOLUTION

Module 26

RELATIONAL INTERVENTIONS AND

ACCOUNTABILITY STATEMENTS

CLINICAL VIGNETTE – “GREAT TAN, BITCH!” THE THERAPIST’S USE OF SELF TO INFORM HER UNDERSTANDING OF THE PATIENT THE PATIENT, JANET, IS A 31 – YEAR – OLD MARRIED WOMAN WHO HAS A HISTORY OF DIFFICULT RELATIONSHIPS WITH ALMOST EVERYONE IN HER LIFE SHE IS PARTICULARLY TROUBLED BY HER LACK OF CLOSE WOMEN FRIENDS OVER THE COURSE OF THE PREVIOUS THREE YEARS, JANET HAS BEEN WORKING HARD IN THE TREATMENT, HAS MADE SUBSTANTIAL GAINS IN HER PROFESSIONAL LIFE, AND HAS VERY MUCH IMPROVED THE QUALITY OF HER RELATIONSHIP WITH HER HUSBAND JANET AND HER THERAPIST (A WOMAN) HAVE HAD A GOOD, RELATIVELY UNCONFLICTED RELATIONSHIP JANET CLEARLY LIKES, AND IS RESPECTFUL OF, HER THERAPIST BUT UPON THE THERAPIST’S RETURN FROM A WEEK – LONG VACATION IN FLORIDA, JANET, AT THE END OF A SESSION, JUST AS SHE IS LEAVING, TURNS BACK TO HER THERAPIST AND, AS A PARTING SHOT, BLURTS OUT “GREAT TAN, BITCH!” THE THERAPIST, AWARE OF FEELING TAKEN ABACK, SAYS NOTHING, SMILES WANLY, AND NODS GOOD – BYE

CLINICAL VIGNETTE – “GREAT TAN, BITCH!” AFTER DISCUSSING THE SITUATION WITH A COLLEAGUE, THE THERAPIST OPENS THE NEXT SESSION WITH THE FOLLOWING

“WE HAVE TALKED A LOT ABOUT HOW UPSETTING IT IS FOR YOU TO HAVE SO FEW WOMEN FRIENDS. I THINK THAT NOW, IN LIGHT OF WHAT HAPPENED AT THE END OF OUR LAST SESSION, I AM COMING TO UNDERSTAND SOMETHING THAT I HAD NEVER BEFORE ENTIRELY UNDERSTOOD. WHEN YOU LEFT LAST TIME, YOUR PARTING WORDS WERE ‘GREAT TAN, BITCH!’ I WONDER IF YOU, BY SAYING THAT, WEREN’T TRYING TO SHOW ME WHAT SOMETIMES HAPPENS FOR YOU WHEN YOU FEEL CLOSE TO A WOMAN AND THEN FIND YOURSELF BECOMING COMPETITIVE.” THE THERAPIST’S AWARENESS OF HER OWN COUNTERTRANSFERENTIAL REACTION OF FEELING TAKEN ABACK AND PUT OFF BY THE PATIENT’S DOOR HANDLE REMARK

TO THE PATIENT’S PROVOCATIVE ENACTMENT ENABLES THE THERAPIST TO OFFER THE PATIENT AN ACCOUNTABILITY STATEMENT THAT CHALLENGES THE PATIENT TO TAKE OWNERSHIP OF HER HOSTILE COMPETITIVENESS

CLINICAL VIGNETTE – “GREAT TAN, BITCH!” THEN THERAPIST AND PATIENT, TOGETHER, MUST WEND THEIR WAY OUT OF WHAT HAS BECOME A MUTUAL ENACTMENT IN THE PROCESS, FINDING THAT BOTH SURVIVE, DISCOVERING, IN ESSENCE, THE INDESTRUCTIBILITY OF EACH

ALTHOUGH THE THERAPIST SHOULD ALWAYS ATTEMPT TO WITHSTAND THE PATIENT’S EFFORTS TO DRAW HER IN TO PARTICIPATING IN THE PATIENT’S DRAMATIC RE – ENACTMENTS, RELATIONAL THEORIES OF THERAPEUTIC ACTION POSTULATE THAT IT IS NOT ONLY INEVITABLE BUT ALSO NECESSARY AND THEREFORE DESIRABLE

THAT ULTIMATELY THE THERAPIST WILL FAIL THE PATIENT AND IN THE VERY WAYS THAT THE PATIENT MOST NEEDS TO BE FAILED IF SHE IS EVER TO DETOXIFY HER INTERNAL BADNESS, REWORK HER INTERNALIZED TRAUMAS, AND OVERCOME HER INTERNAL DEMONS IN OTHER WORDS, IF THERE IS EVER TO BE STRUCTURAL CHANGE

MODEL 3 IS ABOUT ACCOUNTABILITY WHENEVER A PATIENT SAYS OR DOES SOMETHING THAT THE THERAPIST EXPERIENCES AS PROVOCATIVE, I DESCRIBE IT AS A “PROVOCATIVE ENACTMENT” IN ORDER TO GET THE PATIENT TO TAKE OWNERSHIP OF WHAT SHE IS IMPLICITLY ATTEMPTING TO COMMUNICATE

THE THERAPIST HAS THE OPTION OF ASKING THE PATIENT ANY OF THE FOLLOWING

“HOW ARE YOU HOPING THAT I WILL RESPOND?” WHICH ADDRESSES THE ID

“HOW ARE YOU FEARING THAT I MIGHT RESPOND?” WHICH ADDRESSES THE SUPEREGO

“HOW ARE YOU IMAGINING THAT I WILL RESPOND?” WHICH ADDRESSES THE EGO ALL THREE RELATIONAL INTERVENTIONS DEMAND OF THE PATIENT THAT SHE MAKE HER INTERPERSONAL INTENTIONS MORE EXPLICIT THAT SHE TAKE RESPONSIBILITY FOR HER PROVOCATIVE ENACTMENT

MORE GENERALLY

MODEL 1 USES CONFLICT STATEMENTS TO INCREASE THE PATIENT’S AWARENESS OF HER INTERNAL CONFLICTS AND TO PROMPT EVENTUAL TRANSFORMATION OF STRUCTURAL CONFLICT INTO STRUCTURAL COLLABORATION AND ACTUALIZATION OF POTENTIAL MODEL 2 USES DISILLUSIONMENT STATEMENTS TO FACILITATE THE PATIENT’S GRIEVING OF INTOLERABLY PAINFUL DISAPPOINTMENTS AND TO PROMPT EVENTUAL TRANSFORMATION OF RELENTLESS HOPE INTO ACCEPTANCE MODEL 3 USES ACCOUNTABILITY STATEMENTS TO INCREASE THE PATIENT’S AWARENESS OF HER TENDENCY TO PLAY OUT UNMASTERED CHILDHOOD DRAMAS ON THE STAGE OF HER LIFE AND TO PROMPT EVENTUAL TRANSFORMATION OF THOSE COMPULSIVE AND UNWITTING RE – ENACTMENTS INTO ACCOUNTABILITY

MORE SPECIFICALLY

MODEL 3 ACCOUNTABILITY STATEMENTS INVOLVE INTERPRETING THE PATIENT’S ENACTMENTS AS AN EFFORT

EITHER TO DRAW THE THERAPIST IN TO PARTICIPATING AS THE ABUSIVE PARENT BY WAY OF BEHAVIOR ON THE PATIENT’S PART THAT IS UNCONSCIOUSLY DESIGNED TO ELICIT AN ABUSIVE REACTION FROM THE THERAPIST A DIRECT NEGATIVE TRANSFERENCE IN WHICH THE THERAPIST IS MADE INTO THE ABUSIVE PARENT AND THE PATIENT ONCE AGAIN ASSUMES THE ROLE OF THE ABUSED CHILD

OR TO GET THE THERAPIST TO UNDERSTAND FIRSTHAND WHAT IT WAS LIKE FOR THE PATIENT GROWING UP BY WAY OF THE PATIENT’S DOING UNTO THE THERAPIST WHAT WAS ONCE DONE UNTO HER BY THE ABUSIVE PARENT AN INVERTED NEGATIVE TRANSFERENCE IN WHICH THE PATIENT ASSUMES THE ROLE OF THE ABUSIVE PARENT AND BEHAVES AS SUCH IN RELATION TO THE THERAPIST IN ORDER TO MAKE THE THERAPIST UNDERSTAND

ON THE ONE HAND

IT IS CERTAINLY DAUNTING TO IMAGINE THAT A THERAPIST MIGHT EVER BECOME EVEN A LITTLE ABUSIVE IN RELATION TO HER PATIENT ON THE OTHER HAND

IF THE PATIENT HAD AN ABUSIVE PARENT AND THEREFORE INTROJECTED THE VICTIMIZER – VICTIM RELATIONAL DYNAMIC

BUT THE THERAPIST DOES NOT ALLOW HERSELF TO BE DRAWN IN TO PARTICIPATING COUNTERTRANSFERENTIALLY IN WHATEVER WAY THE PATIENT MIGHT NEED HER TO, THEN THE THERAPIST WILL BE ROBBING THE PATIENT OF A PRIME OPPORTUNITY TO REWORK HER SENSE OF HERSELF AS BAD AND OF THE WORLD AS BAD BY PLAYING OUT THE DYSFUNCTIONAL DYNAMIC OF SELF – SABOTAGE AND VICTIMIZATION ON THE STAGE OF HER LIFE INDEED IT MAY WELL BE ONLY BY WAY OF RECREATING WITH HER THERAPIST THE ONLY KIND OF RELATIONSHIP SHE HAS EVER KNOWN, THAT THE PATIENT WILL BE AT LAST ABLE TO NEGOTIATE WITH HER THERAPIST A DIFFERENT ENDING

MODEL 3 ACCOUNTABILITY STATEMENTS ADDRESS THE ISSUE OF OWNERSHIP BE IT ON THE PART OF THE PATIENT OR THE THERAPIST AND WHETHER IT INVOLVES A DIRECT NEGATIVE TRANSFERENCE OR AN INVERTED NEGATIVE TRANSFERENCE

“IT OCCURS TO ME THAT YOU, BY WAY OF YOUR BEHAVIOR IN HERE WITH ME, ARE HELPING ME TO UNDERSTAND SOMETHING THAT I HAD NEVER BEFORE ENTIRELY UNDERSTOOD …” “I THINK THAT YOU HAVE BEEN TRYING TO COMMUNICATE SOMETHING IMPORTANT TO ME THAT I HAD BEEN REFUSING TO RECOGNIZE …” “I WONDER IF MY DIFFICULTY APPRECIATING JUST HOW DESPERATE YOU WERE MADE YOU FEEL THAT YOU HAD TO DO SOMETHING DRAMATIC IN ORDER TO GET MY ATTENTION …”

IN ESSENCE

THE THERAPIST IS HERE HOLDING HERSELF ACCOUNTABLE FOR HER CONTRIBUTION TO THE PATIENT’S ENACTMENT

FURTHERMORE FRAMING THE PATIENT’S PROVOCATIVE TRANSFERENTIAL ACTIVITY IN THIS WAY THAT IS, AS AN UNDERSTANDABLE REACTION TO THE THERAPIST’S INABILITY / REFUSAL TO UNDERSTAND SOMETHING IMPORTANT ABOUT THE PATIENT’S INTERNAL EXPERIENCE

MAY THEN MAKE IT A LITTLE EASIER FOR THE PATIENT HERSELF TO TOLERATE BEING HELD ACCOUNTABLE IN OTHER WORDS

WHEN THE THERAPIST ACKNOWLEDGES HER PART, THE PATIENT MAY THEN BE ABLE TO ACKNOWLEDGE HER PART WITHOUT LOSING FACE

Module 27

CONTAINMENT AND

THE CAPACITY TO RELENT

TO REVIEW

PROJECTIVE IDENTIFICATION BE IT A DIRECT OR AN INVERTED NEGATIVE TRANSFERENCE

THE INDUCTION PHASE BY DELIVERING HER PATHOGENIC INTROJECTS INTO THE RELATIONSHIP WITH HER THERAPIST, THE PATIENT DRAWS THE THERAPIST IN TO PARTICIPATING COUNTERTRANSFERENTIALLY IN THE PATIENT’S TRANSFERENTIAL ENACTMENT

THE RESOLUTION PHASE RESOLUTION IS ACHIEVED ONCE THE THERAPIST BRINGS TO BEAR HER OWN, MORE – EVOLVED CAPACITY TO PROCESS AND INTEGRATE THAT IS, TO DETOXIFY PATHOGENICITY

ON BEHALF OF A PATIENT WHO TRULY DOES NOT KNOW HOW THEREBY RETURNING TO THE PATIENT FOR RE – INTROJECTION A SLIGHTLY DETOXIFIED VERSION OF THE ORIGINAL TOXIC BOLUS

IN ESSENCE

A SYMBOLIC REPETITION OF THE ORIGINAL RELATIONAL TRAUMA BUT WITH A MUCH HEALTHIER RESOLUTION THIS TIME THE EXPERIENCE OF BAD – BECOME – GOOD

INDEED,

THE HALLMARK OF A SUCCESSFUL

PROJECTIVE IDENTIFICATION IS THE THERAPIST’S CAPACITY TO TOLERATE WHAT THE PATIENT FINDS INTOLERABLE

PROVISION OF CONTAINMENT THE MODEL 3 THERAPIST MUST BE ABLE NOT ONLY TO TOLERATE BEING MADE INTO THE PATIENT’S OLD BAD OBJECT BUT ALSO ONCE THE THERAPIST HAS ALLOWED HERSELF TO BE DRAWN IN TO WHAT HAS BECOME A MUTUAL ENACTMENT

TO EXTRICATE HERSELF BY STEPPING BACK THEREBY RECOVERING HER OBJECTIVITY AND HER THERAPEUTIC EFFECTIVENESS

MOST IMPORTANTLY

THE THERAPIST MUST HAVE THE CAPACITY TO RELENT THE THERAPIST MUST HAVE BOTH THE WISDOM TO RECOGNIZE AND THE INTEGRITY TO ACKNOWLEDGE CERTAINLY TO HERSELF, PERHAPS TO THE PATIENT AS WELL

HER OWN PARTICIPATION IN THE DRAMA THAT IS BEING PLAYED OUT BETWEEN THEM ON THE STAGE OF THE TREATMENT

IN ESSENCE, THE THERAPIST MUST BE ABLE

BOTH TO RELENT AND TO HOLD HERSELF ACCOUNTABLE FOR HER OWN ENACTMENTS

IF THE THERAPIST NEVER ALLOWS HERSELF TO BE DRAWN IN TO PARTICIPATING WITH THE PATIENT IN HER ENACTMENTS

FAILURE OF ENGAGEMENT AND LOST OPPORTUNITY IF, HOWEVER, THE THERAPIST ALLOWS HERSELF TO BE DRAWN IN TO THE PATIENT’S INTERNAL DRAMAS BUT THEN GETS LOST

FAILURE OF CONTAINMENT AND THE POTENTIAL FOR RETRAUMATIZATION

ALTHOUGH INITIALLY THE THERAPIST MIGHT INDEED FAIL THE PATIENT IN MUCH THE SAME WAYS THAT HER PARENT HAD FAILED HER

THE INDUCTION PHASE ULTIMATELY THE THERAPIST WILL CHALLENGE THE PATIENT’S PROJECTIONS BY LENDING ASPECTS OF HER “OTHERNESS” TO THE INTERACTION OR, AS WINNICOTT (1965) WOULD HAVE SAID, HER “EXTERNALITY”

SUCH THAT THE PATIENT WILL HAVE THE EXPERIENCE OF SOMETHING THAT IS “OTHER – THAN – ME” AND CAN TAKE THAT IN

THE RESOLUTION PHASE

WHAT THE PATIENT THEN INTROJECTS WILL BE AN AMALGAM, PART CONTRIBUTED BY THE THERAPIST SOMETHING MORE PROCESSED, INTEGRATED, AND DETOXIFIED

AND PART CONTRIBUTED BY THE PATIENT THE ORIGINAL PROJECTION PARENTHETICALLY

IN THE PSYCHOANALYTIC LITERATURE, “INTERNALIZE” TENDS TO IMPLY “POSITIVE” AS IN “TRANSMUTING INTERNALIZATION”

WHEREAS “INTROJECT” TENDS TO IMPLY “NEGATIVE” AS IN “PATHOGENIC INTROJECT”

AND BECAUSE THE THERAPIST IS NOT, IN FACT, AS BAD AS THE PARENT HAD BEEN, THERE CAN BE A HEALTHIER RESOLUTION THIS TIME

THERE WILL BE REPETITION OF THE ORIGINAL TRAUMA BUT EVENTUAL INCREMENTAL DETOXIFICATION OF THE PATIENT’S INTERNAL WORLD AND INTEGRATION AT A HIGHER LEVEL OF ACCOUNTABILITY

SERIAL DILUTIONS GRADUATED DETOXIFICATION

THE ITERATIVE CYCLES OF INDUCTION AND RESOLUTION “MORE OF SAME” AND THEN “SOMETHING NEW”

WILL HAPPEN REPEATEDLY

RESULTING ULTIMATELY IN STRUCTURAL MODIFICATION NOTE THAT IT IS THE SECOND (RESOLUTION) PHASE OF THE PROJECTIVE IDENTIFICATION THAT CONSTITUTES THE CHALLENGE AND THE FIRST (INDUCTION) PHASE THAT REINFORCES AND SUPPORTS THE DYSFUNCTIONAL STATUS QUO

AGAIN

IT IS NOT ONLY INEVITABLE BUT ALSO NECESSARY AND THEREFORE DESIRABLE

THAT ULTIMATELY THE THERAPIST WILL FAIL THE PATIENT AND IN THE VERY WAYS THAT THE PATIENT MOST NEEDS TO BE FAILED IF SHE IS EVER TO HAVE AN OPPORTUNITY TO REWORK HER INTERNAL BADNESS

THE THERAPIST’S CAPACITY TO TOLERATE “BEING BAD” (CONTINUED)

IF THE MODEL 2 THERAPIST CANNOT TOLERATE “BREAKING THE PATIENT’S HEART” EVERY NOW AND AGAIN, THE THERAPIST WILL BE ROBBING THE PATIENT OF THE OPPORTUNITY ADAPTIVELY TO INTERNALIZE MISSING PSYCHOLOGICAL FUNCTIONS VIA OPTIMAL DISILLUSIONMENT AND TRANSMUTING INTERNALIZATION

SO TOO IF THE MODEL 3 THERAPIST REFUSES TO PARTICIPATE AT LEAST EVERY NOW AND AGAIN AS SOMEONE WHO “INITIALLY RETRAUMATIZES BUT ULTIMATELY RELENTS,” THE THERAPIST WILL BE ROBBING THE PATIENT OF THE OPPORTUNITY TO REWORK VIA SERIAL DILUTIONS

HER INTROJECTED BOLUSES OF TOXICITY

THE THERAPIST’S CAPACITY TO TOLERATE “BEING BAD” BECAUSE THE ORIGINAL “HEARTBREAK” (MODEL 2) AND “ABUSE” (MODEL 3) OCCURRED IN THE CONTEXT OF THE THERE – AND – THEN ENGAGEMENT BETWEEN PARENT AND CHILD, IT STANDS TO REASON THAT THE REWORKING OF THOSE EARLY – ON RELATIONAL TRAUMAS WILL NEED TO OCCUR IN THE CONTEXT OF THE HERE – AND – NOW ENGAGEMENT BETWEEN THERAPIST AND PATIENT IN OTHER WORDS

BECAUSE THE ETIOLOGY INVOLVED FAILURES AT THE INTIMATE EDGE BETWEEN PARENT AND CHILD, THE THERAPEUTIC ACTION SHOULD INVOLVE RENEGOTIATING AT LEAST SOME VERSION OF THOSE RELATIONAL FAILURES AT THE INTIMATE EDGE BETWEEN THERAPIST AND PATIENT

“IF THE THERAPIST DOES NOT PARTICIPATE AS A NEW GOOD OBJECT, THE THERAPY MAY NEVER GET UNDER WAY. BUT IF SHE DOES NOT PARTICIPATE AS THE OLD BAD ONE, IT MAY NEVER END.” (GREENBERG 1986)

WHICH CAPTURES EXQUISITELY THE DELICATE BALANCE BETWEEN THE THERAPIST’S PARTICIPATION AS A NEW GOOD OBJECT SO THAT THERE CAN BE A STARTING OVER

AND THE THERAPIST’S PARTICIPATION AS THE OLD BAD ONE SO THAT THERE CAN BE AN OPPORTUNITY TO ACHIEVE BELATED MASTERY OF THE INTROJECTED TRAUMAS AND ABUSE

BY THE SAME TOKEN, IF THE THERAPIST DOES NOT PARTICIPATE AS THE OLD BAD OBJECT, THE THERAPY MAY NEVER GET UNDER WAY BUT IF SHE DOES NOT PARTICIPATE AS A NEW GOOD ONE, IT MAY NEVER END

IN SUM

OVER THE COURSE OF A TREATMENT THE PATIENT SHOULD THEREFORE HAVE AN OPPORTUNITY TO EXPERIENCE HER THERAPIST AS BOTH A NEW GOOD OBJECT AND THE OLD BAD ONE MODEL 2 – STRUCTURAL GROWTH BY WORKING THROUGH THE EXPERIENCE OF GOOD – BECOME – BAD DISILLUSIONMENT / POSITIVE TRANSFERENCE DISRUPTED

MODEL 3 – STRUCTURAL MODIFICATION BY WORKING THROUGH THE EXPERIENCE OF BAD – BECOME – GOOD NEGATIVE TRANSFERENCE

Module 28

INTROJECTIVE IDENTIFICATION AND

A CERTAIN BEAUTY IN BROKENNESS

MODEL 3 AS WE KNOW

IF EARLY – ON TRAUMA AND ABUSE EXPERIENCED BY THE CHILD AT THE HANDS OF HER PARENT CANNOT BE PROCESSED AND INTEGRATED INTO HEALTHY PSYCHIC STRUCTURE, THEN THE UNMASTERED EXPERIENCE WILL BECOME STRUCTURALIZED IN THE MIND OF THE DEVELOPING CHILD AS INTERNAL BADNESS THE CLINICAL CHALLENGE WILL THEN BE – ONCE TRAUMATIZING EXPERIENCE HAS BECOME INTERNALLY RECORDED AS BADNESS, HOW CAN IT LATER BE ACCESSED IN THE TREATMENT AND DETOXIFIED?

PROJECTIVE IDENTIFICATION AND INTROJECTIVE IDENTIFICATION

PROJECTIVE IDENTIFICATION “RELATIONAL DISCONFIRMATION OF TOXIC EXPECTATION”

THE INDUCTION PHASE COMMENCES ONCE THE PATIENT PROJECTS ONTO THE THERAPIST SOME ASPECT OF THE PATIENT’S EXPERIENCE THAT HAS BEEN TOO TOXIC FOR THE PATIENT TO PROCESS AND INTEGRATE AND THEN EXERTS PRESSURE ON THE THERAPIST TO ACCEPT THAT PROJECTION, THEREBY INDUCTING THE THERAPIST INTO THE PATIENT’S ENACTMENT THE RESOLUTION PHASE IS USHERED IN ONCE THE THERAPIST STEPS BACK FROM HER PARTICIPATION IN WHAT HAS BECOME A MUTUAL ENACTMENT AND BRINGS TO BEAR HER OWN, MORE – EVOLVED CAPACITY TO PROCESS AND INTEGRATE ON BEHALF OF A PATIENT WHO TRULY DOES NOT KNOW HOW – SUCH THAT WHAT IS THEN REINTROJECTED BY THE PATIENT CAN BE MORE EASILY ASSIMILATED INTO HEALTHY PSYCHIC STRUCTURE AND, IF ALL GOES WELL, THESE CYCLES WILL HAPPEN REPEATEDLY, THE NET RESULT OF WHICH WILL BE GRADUAL DETOXIFICATION OF THE PATIENT’S INTERNAL TOXICITY

INTROJECTIVE IDENTIFICATION

(STARK 2015)

“RELATIONAL DILUTION OF TOXIC EXPERIENCE”

THIS CONCEPT DESCRIBES WHAT HAPPENS NOT WHEN THE PATIENT INITIATES THE THERAPEUTIC ACTION BY EXERTING PRESSURE ON THE THERAPIST TO TAKE ON, AS THE THERAPIST’S OWN, SOME ASPECT OF THE PATIENT’S UNMASTERED EXPERIENCE BUT RATHER WHEN THE THERAPIST INITIATES THE THERAPEUTIC ACTION BY INTUITIVELY AND NOT ALTOGETHER UNCONSCIOUSLY

ENTERING INTO THE PATIENT’S INTERNAL WORLD AND TAKING ON, AS THE THERAPIST’S OWN, SOME ASPECT OF THE PATIENT’S UNMASTERED EXPERIENCE THIS TAKES PLACE IN NOT ONLY THE THERAPIST – PATIENT RELATIONSHIP BUT ALSO THE PARENT – INFANT RELATIONSHIP CERTAINLY A GOOD MOTHER WHO IS ATTUNED TO HER INFANT’S MOMENT – BY – MOMENT EXPERIENCE WILL USE INTROJECTIVE IDENTIFICATION AS A MATTER OF COURSE

INTROJECTIVE IDENTIFICATION “RELATIONAL DILUTION OF TOXIC EXPERIENCE” MORE SPECIFICALLY

AN AUTHENTICALLY ENGAGED MOTHER, SENSING HER INFANT’S DISTRESS, WILL ENTER INTO THE INFANT’S DYSREGULATED AFFECTIVE STATE AND TAKE IT ON AS HER OWN, LENDING ASPECTS OF HER OWN, MORE – EVOLVED CAPACITY TO A PROCESSING AND INTEGRATING OF HER CHILD’S UNMASTERED EXPERIENCE THE MOTHER WILL DO THIS INTUITIVELY AND REPEATEDLY, THE NET RESULT OF WHICH WILL BE DILUTION AND MODULATION OF HER CHILD’S EXPERIENCE OF DISTRESS – AND EVENTUAL DEVELOPMENT OF THE CHILD’S CAPACITY TO MANAGE OVERWHELMING AFFECT ON HER OWN AS THIS PROCESS CONTINUES, THE CHILD’S NEED FOR EXTERNAL REGULATION OF THE SELF WILL BECOME TRANSFORMED, OVER TIME, INTO THE CAPACITY TO BE INTERNALLY SELF – REGULATING WHETHER RELATIONAL DISCONFIRMATION OF TOXIC EXPECTATION OR RELATIONAL DILUTION OF TOXIC EXPERIENCE THE NET RESULT WILL BE STRUCTURAL MODIFICATION OF THE INTROJECTED BADNESS

WITH PROJECTIVE IDENTIFICATION, IT WILL BE THE PATIENT WHO INITIATES THE THERAPEUTIC ACTION WHEREAS WITH INTROJECTIVE IDENTIFICATION, IT WILL BE THE THERAPIST

BUT WHETHER RELATIONAL DISCONFIRMATION OF TOXIC EXPECTATION OR RELATIONAL DILUTION OF TOXIC EXPERIENCE, THE NET RESULT WILL BE STRUCTURAL MODIFICATION OF DYSFUNCTIONAL RELATIONAL DYNAMICS AND INTROJECTED BOLUSES OF TOXICITY BY WAY OF NEGOTIATING THE VICISSITUDES THAT WILL INEVITABLY ARISE AT THE INTIMATE EDGE OF AUTHENTIC ENGAGEMENT BETWEEN TWO RELATIONAL OBJECTS WHO ARE EVER BUSY “MUTUALLY IMPROVISING” (HARTMAN 2016) AS THEY CHOREOGRAPH THEIR INTERACTIVE STEPS

WORKING THROUGH PROJECTIVE IDENTIFICATION REQUIRES OF THE MODEL 3 THERAPIST THAT SHE BE ABLE TO TOLERATE BEING MADE AS BAD AS THE PATIENT MIGHT NEED HER TO BE WITHOUT LOSING HER OWN SELF FOR TOO LONG WORKING THROUGH INTROJECTIVE IDENTIFICATION REQUIRES OF THE MODEL 3 THERAPIST THAT SHE BE ABLE TO TOLERATE BEING OVERWHELMED BY THE INTENSITY OF THE PATIENT’S DYSREGULATED AFFECT WITHOUT LOSING HER OWN SELF FOR TOO LONG IN OTHER WORDS

IT IS IMPORTANT THAT THE THERAPIST BE ABLE TO LOSE HER SELF EVERY NOW AND AGAIN (INDUCTION PHASE) BUT THAT SHE NOT GET SO LOST THAT SHE CANNOT THEN REFIND HER SELF (RESOLUTION PHASE)

CONTAINMENT AND ACCOUNTABILITY WHETHER BY WAY OF DISCONFIRMATION OF TOXIC EXPECTATION (PROJECTIVE IDENTIFICATION) OR DILUTION OF TOXIC EXPERIENCE (INTROJECTIVE IDENTIFICATION)

THE RELATIONAL PERSPECTIVE IS ULTIMATELY A STORY ABOUT THE THERAPIST’S USE OF SELF TO FACILITATE MODIFICATION OF THE PATIENT’S SENSE OF SELF AS BAD THEREBY DEFUSING THE PATIENT’S NEED TO PLAY OUT HER BADNESS ON THE STAGE OF HER LIFE

AS IRRESPONSIBLE RE – ENACTMENT IS GRADUALLY REPLACED BY RESPONSIBLE ACCOUNTABILITY

IN CONCLUSION J THANK YOU SO MUCH FOR TAKING THIS JOURNEY WITH ME AND FOR SEEING IT THROUGH TO THE END MOST IMPORTANTLY

I HOPE YOU HAVE ENJOYED YOURSELVES AND NOW HAVE ADDITIONAL WAYS TO CONCEPTUALIZE AND FRAME THE WORK THAT YOU DO WITH SUCH PASSION AND COMMITMENT

IN CLOSING

I WOULD LIKE TO BORROW FROM STEPHEN MITCHELL A WONDERFUL ANECDOTE THAT CAPTURES THE ESSENCE OF THE QUINTESSENTIAL STRUGGLE IN WHICH ALL OF US THERAPISTS ARE ENGAGED AS WE ATTEMPT TO MASTER OUR ART MITCHELL (1988) WRITES –

“<STRAVINSKY> HAD WRITTEN A NEW PIECE WITH A DIFFICULT VIOLIN PASSAGE. AFTER IT HAD BEEN IN REHEARSAL FOR SEVERAL WEEKS, THE SOLO VIOLINIST CAME TO STRAVINSKY AND SAID HE WAS SORRY, HE HAD TRIED HIS BEST, THE PASSAGE WAS TOO DIFFICULT; NO VIOLINIST COULD PLAY IT. STRAVINSKY SAID, ‘I UNDERSTAND THAT. WHAT I AM AFTER IS THE SOUND OF SOMEONE TRYING TO PLAY IT.’” AS THERAPISTS, OUR WORK IS EXQUISITELY DIFFICULT AND FINELY TUNED – AND OFTEN WE WILL NOT BE ABLE TO GET IT JUST RIGHT – PERHAPS, HOWEVER, WE CAN CONSOLE OURSELVES WITH THE THOUGHT THAT IT IS THE EFFORT WE MAKE TO GET IT JUST RIGHT THAT WILL ULTIMATELY COUNT

OPTIMAL STRESS STRONGER AT THE BROKEN PLACES IS THERE NOT A CERTAIN BEAUTY IN BROKENNESS, A BEAUTY NEVER ACHIEVED BY THINGS UNBROKEN? IF A BONE IS FRACTURED AND THEN HEALS, THE AREA OF THE BREAK WILL BE STRONGER THAN THE SURROUNDING BONE AND WILL NOT AGAIN EASILY FRACTURE ARE WE TOO NOT STRONGER AT OUR BROKEN PLACES? IS THERE NOT A CERTAIN BEAUTY IN BROKENNESS, A QUIET STRENGTH WE ACQUIRE FROM SURVIVING ADVERSITY AND HARDSHIP AND MASTERING THE EXPERIENCE OF DISAPPOINTMENT, HEARTBREAK, AND DEVASTATION? AND, THEN, WHEN WE FINALLY RISE ABOVE IT, DON’T WE RISE UP IN QUIET TRIUMPH, EVEN IF ONLY WE NOTICE …

References

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